NCLEX-RN Fundamentals Sample

Question 1

A nurse is caring for four clients on a med-surg unit. Which client should the nurse assess first?

Accepted Answer

New onset confusion paired with hypoxemia points to acute oxygenation or perfusion failure, which sits at the top of the airway, breathing, circulation hierarchy. The other findings are abnormal but expected, stable, or routine to manage. The nurse must lay eyes on the hypoxic, confused client first to rule out a deteriorating airway, pulmonary embolism, or stroke before doing anything else on the floor.

Using Maslow and the ABC framework, oxygenation outranks pain, glucose control, and discharge teaching every time. A saturation of 88 percent in an alert person would already trigger action; with confusion layered on top it is an emergency.

Question 2

A nurse is preparing to administer 0.9 percent normal saline to a client with severe dehydration. Which finding would cause the nurse to hold the infusion and notify the provider?

Accepted Answer

Bibasilar crackles suggest fluid is already pooling in the lungs. Pushing more isotonic fluid into a client whose lungs cannot keep up will worsen pulmonary edema and can drop oxygenation fast. The nurse should pause, call the provider, and reassess the volume plan.

A mild tachycardia, low urine output, and borderline blood pressure are exactly what you would expect in dehydration and are the reasons the saline was ordered in the first place. Crackles are the safety stop, not the indication.

Question 3

A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which intervention should the nurse anticipate first?

Accepted Answer

A potassium of 6.2 is dangerous because of what it does to the heart, not the kidney. The first nursing priority is to get the client on continuous cardiac monitoring and pull a 12 lead ECG to look for peaked T waves, widened QRS, or arrhythmia. That assessment drives whether the team needs calcium to stabilize the membrane, insulin and dextrose to shift potassium, or dialysis to remove it.

Monitoring is a fast, low cost step that catches deterioration early. The treatments listed in the other choices may all be needed, but each is selected based on what the monitor and ECG show.

Question 4

Which client statement indicates correct understanding of warfarin therapy?

Accepted Answer

Warfarin works by blocking vitamin K dependent clotting factors, so wide swings in dietary vitamin K (mostly from leafy greens) make the INR unstable. The goal is consistency, not avoidance. Eating roughly the same amount of greens week to week lets the dose stay reliable.

Doubling missed doses, adding NSAIDs, or stopping warfarin without a provider order all increase risk of bleeding or clotting. Steady habits and lab follow up keep the medication safe.

Question 5

A nurse is delegating care on a busy med-surg floor. Which task is appropriate to assign to unlicensed assistive personnel?

Accepted Answer

Routine vital signs on a stable client are within scope for unlicensed assistive personnel. The nurse remains responsible for interpreting the values, but collecting them is a delegated task.

Assessment, teaching, and titration of medications all require nursing judgment and cannot be delegated. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.

Question 6

A client receiving a unit of packed red blood cells reports chills and lower back pain 10 minutes into the transfusion. The nurse's first action is to:

Accepted Answer

Chills and back pain during a transfusion can mean an acute hemolytic reaction, which is potentially fatal. The first action is to stop the transfusion immediately, then keep the line open with normal saline through new tubing so vascular access is preserved for emergency treatment. Vital signs, provider notification, and lab samples follow.

Slowing, premedicating, or swapping the unit before stopping risks pushing more incompatible blood into the client. The rule is stop, save the line, then escalate.

Question 7

A client with type 1 diabetes presents with deep, rapid breathing, fruity breath, and a blood glucose of 482 mg/dL. Which is the priority nursing action?

Accepted Answer

These findings point to diabetic ketoacidosis. The very first life threat in DKA is severe volume depletion, not the glucose level itself. Restoring circulating volume with normal saline supports perfusion and dilutes glucose before insulin is started. Insulin too early in a dehydrated client can drive potassium into cells and trigger dangerous hypokalemia.

After saline is running and electrolytes are checked, an IV insulin infusion follows. Subcutaneous routes are too slow and unreliable in DKA, and oral carbs make the situation worse.

Question 8

A nurse is reviewing morning labs. Which result requires the most urgent provider notification?

Accepted Answer

A platelet count of 22,000 in a client receiving heparin raises concern for heparin induced thrombocytopenia. HIT is paradoxical because it causes both bleeding risk from low platelets and clotting risk from antibody driven platelet activation. Heparin must be stopped and an alternative anticoagulant ordered.

The other values are abnormal but expected for the conditions named. None carries the same immediate, drug related danger as a possible HIT presentation.

Question 9

A client is receiving morphine via patient controlled analgesia. The nurse finds the client with a respiratory rate of 7 and difficulty arousing. The first action is to:

Accepted Answer

Opioid induced respiratory depression is the suspected event. The first action is to stop the source by clamping or pausing the PCA and immediately assess airway, breathing, and circulation. Stimulating the client and supporting ventilation often restores adequate breathing on its own.

Naloxone may be needed shortly after, but is not the very first move; pumping naloxone into a client whose airway is obstructed will not save them. Documentation and positioning come after airway and breathing are secured.

Question 10

A nurse is teaching a client with newly diagnosed hypertension. Which lifestyle change has the greatest evidence based impact on blood pressure?

Accepted Answer

Evidence consistently shows the DASH eating pattern combined with sodium reduction lowers blood pressure by clinically meaningful amounts, often comparable to a single medication. It is the strongest first line lifestyle change, alongside weight loss, regular activity, and limiting alcohol.

The other options are not harmful but do not match DASH and sodium control in measurable benefit.