Lippincott Style NCLEX Questions

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Lippincott-Style NCLEX Questions with RationalesQuestion 1: A nurse is caring for a client with heart failure who is receiving furosemide.Which assessment finding requires immediate action? (Variation 12) (Select all that apply)A. Potassium level of 3.0 mEq/LB. Blood pressure of 110/70 mmHgC. Heart rate of 80 bpmD. Reports of nauseaCorrect Answer: A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHgRationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0mEq/L, B.Blood pressure of 110/70mmHgis correct becauseitpreventscomplicationsandensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) andMaslows hierarchy.Question 2: A nurse is educating a client on warfarin therapy. Which statement indicates aneed for further teaching? (Variation 8)A 'I will avoid green leafy vegetables.'B. 'I will use an electric razor to shave.'C. ‘I will take ibuprofen for headaches."□. "I will have regular blood tests to monitor my INR.'Correct Answer: C. I will take ibuprofen for headaches/Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen forheadaches." is correct because it prevents complications and ensures safe client care. Nursingpriorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 3: A nurse is caring for a client with heart failure who is receiving furosemide.Which assessment finding requires immediate action? (Variation 18)A Potassium level of 3.0 mEq.'LB. Blood pressure of 110/70 mmHgC. Heart rate of 80 bpm□. Reports of nauseaCorrect Answer: A. Potassium level of 3.0 mEq/LRationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0mEq/L is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 4: A client with diabetes mellitusreports shakiness and confusion. The nurseshould first: (Variation 1) (Select all that apply)A Check the client's blood glucoseB. Administer insulin

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C. Give a high-protein snackD. Encourage fluidsCorrect Answer: A. Check the client's blood glucose, B. Administer insulinRationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's bloodglucose, B. Administer insulin is correct because it prevents complications and ensures safe clientcare. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question5: A nurse is assessinga client with chronic obstructive pulmonary disease(COPD). Which finding is most concerning? (Variation 5)A Barrel-shaped chestB. Clubbing of fingersC. Oxygen saturation of 88%D. Respiratory rate of 22 breaths,''minCorrect Answer: B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers iscorrect because it prevents complications and ensures safe client care. Nursing priorities follow theABCs (airway breathing, circulation) and Maslows hierarchy.Question 6: A nurse is caring for a client with pneumonia. Which nursing intervention is thepriority? (Variation 9) (Which intervention is the priority?)A Encourage oral fluidsB. Obtain a sputumcultureC. Administer oxygen therapyD. Monitor temperatureCorrect Answer: C. Administer oxygen therapyRationale: Rationale: The correct answer aligns with nursing standards. C. Administeroxygentherapy is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 7: A nurse is assessinga client with chronic obstructive pulmonary disease(COPD). Which finding is most concerning? (Variation 8) (Select all that apply)A Barrel-shaped chestB. Clubbing of fingersC. Oxygen saturation of 88%D. Respiratory rate of 22 breaths/minCorrect Answer: A. Barrel-shaped chest, B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. A. Barrel-shaped chest, B.Clubbing of fingers is correct because it prevents complications and ensures safe client care.Nursing priorities follow the ABCs (airway breathing, circulation) and Maslows hierarchy.Question 8: A nurse is educating a client on warfarin therapy. Which statement indicates a

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need for further teaching? (Variation 6) (Which task should the nurse delegate?)A'I willavoid green leafy vegetables.1B. 1willuse an electric razor to shave.1C.’Iwill take ibuprofen for headaches.’□. ’I will have regular blood tests to monitor my INR.'Correct Answer: C . ’I will take ibuprofen for headaches.’Rationale: Rationale: The correct answer aligns with nursing standards. C. 1 will take ibuprofen forheadaches.' is correct becauseitprevents complicationsandensures safe client care. Nursingpriorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question9: A nurseis assessinga client withchronicobstructivepulmonarydisease(COPD). Which finding is most concerning? (Variation 19)A Barrel-shaped chestB. Clubbing of fingersC. Oxygen saturation of 88%D. Respiratory rate of 22 breaths/minCorrect Answer: B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers iscorrect because it prevents complications and ensures safe client care. Nursing priorities follow theABCs (airway, breathing, circulation) and Maslows hierarchy.Question 10: A nurse is educating a client on warfarin therapy. Which statement indicates aneed for further teaching? (Variation 12} (Select all that apply)A ’Iwillavoid green leafy vegetables.1B. ’Iwilluse an electric razor to shave.1C.’Iwill take ibuprofen for headaches.'D.’Iwill have regular blood tests to monitor my INR.'Correct Answer: A. 'I will avoid green leafy vegetables.', B. 'I will use an electric razor toshave.’Rationale: Rationale: The correct answer aligns with nursing standards. A. 'I will avoid green leafyvegetables.’, B. 1 will use an electric razor to shave.’ is correct because it prevents complicationsand ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) andMaslows hierarchy.Question 11: A client with diabetes mellitus reports shakiness and confusion. The nurseshould first: (Variation 6) (Which intervention is the priority?)A Check the client’sbloodglucoseB. AdministerinsulinC. Give a high-protein snackD. Encourage fluidsCorrect Answer: A. Check the client's blood glucose

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Rationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's bloodglucose is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway, breathing, circulation) and Maslowrs hierarchy.Question 12: A nurse is caring for a client with heart failure who is receiving furosemide.Which assessment finding requires immediate action? (Variation 14)A Potassium level of 3.O' mEq/LB. Blood pressure of 110/70 mmHgC. Heart rate of 80 bpmD. Reports of nauseaCorrect Answer: A. Potassium level of 3.0 mEq/LRationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0mEq/L is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway breathing, circulation) and Maslows hierarchy.Question 13: A client with diabetes mellitus reports shakiness and confusion. The nurseshould first: (Variation 15} (Select all that apply)A Check the client’s blood glucoseB. AdministerinsulinC. Give a high-protein snackD. Encourage fluidsCorrect Answer: A. Check the client's blood glucose. B. Administer insulinRationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's bloodglucose, B. Administerinsulin iscorrect because it prevents complications and ensures safeclientcare. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 14: A nurse is educating a client on warfarin therapy. Which statement indicates aneed for further teaching? (Variation 13)A 'Iwillavoid green leafy vegetables.'B. ’I will use an electric razor to shave.'C.’I will take ibuprofenfor headaches.’D.'Iwill have regular blood tests to monitor myINR.'Correct Answer: C. 'I will take ibuprofen for headaches.’Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen forheadaches.’ is correct because it prevents complications and ensures safe client care. Nursingpriorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 15: A client with diabetes mellitus reports shakiness and confusion. The nurseshould first: (Variation 20) (Which task should the nurse delegate?)A Check the client's blood glucoseB. AdministerinsulinC. Give a high-protein snack

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D. Encourage fluidsCorrect Answer: A. Check the client's blood glucoseRationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's bloodglucose is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway breathing, circulation) and Maslows hierarchy.Question 16: A nurse is caring for a client with heart failure who is receiving furosemide.Which assessment finding requires immediate action? (Variation 4) (Select all that apply)A Potassium level of 3.0 mEq/LB. Blood pressure of 110/70 mmHgC. Heart rate of 80 bpmD. Reports of nauseaCorrect Answer: A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHgRationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0mEq/L, B. Blood pressure of 110/70 mmHg is correct because it prevents complications andensures safe client care. Nursing priorities follow the ABCs (airway breathing, circulation) andMaslows hierarchy.Question 17: A nurse is caring for a client with heart failure who is receiving furosemide.Which assessment finding requires immediate action? (Variation 6)A Potassium level of 3.0 mEq/LB. Blood pressure of 110/70 mmHgC. Heart rate of 80 bpmD. Reports of nauseaCorrect Answer: A. Potassium level of 3.0 mEq/LRationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0mEq/L is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway breathing, circulation) and Maslows hierarchy.Question 18: A nurse is educatingaclient on warfarin therapy. Which statement indicates aneed for further teaching? (Variation?)A 'I will avoid green leafy vegetables.'B. 'I will use an electric razor to shave.'C.'I will take ibuprofenfor headaches.'D.'Iwill have regular blood tests to monitor myINR.'Correct Answer: C. 'I will take ibuprofen for headaches.'Rationale: Rationale: The correct answer aligns with nursing standards. C.1will take ibuprofen forheadaches.' is correct becauseitprevents complicationsandensures safe client care. Nursingpriorities follow the ABCs (airway, breathing, circulation) and Maslowshierarchy.Question 19: A nurse is educating a client on warfarin therapy. Which statement indicates a

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need for further teaching? (Variation 20) (Select all that apply)A. 'Iwillavoid green leafy vegetables.’B. 'I will use an electric razor to shave.’C.'Iwill take ibuprofen for headaches.'. 'I will have regular blood tests to monitor myINR.’Correct Answer: A. ’I will avoid green leafy vegetables.1, B. 'I will use an electric razor toshave.'Rationale: Rationale: The correct answer aligns with nursing standards.A.’I will avoid greenleafyvegetables ', B. 'I will use an electric razor to shave.' is correct because it prevents complicationsand ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation ) andMaslows hierarchy.Question 20: A nurse is educating□client on warfarin therapy. Which statement indicates aneed for further teaching? (Variation 17)A ’Iwillavoid green leafy vegetables.’B. ’Iwilluseanelectricrazorto shave.'C. 'I will take ibuprofen for headaches/D. 'I will have regular blood tests to monitor myINR.’Correct Answer: C . ’I will take ibuprofen for headaches.’Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen forheadaches/ is correct because it prevents complications and ensures safe client care. Nursingpriorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 21: A nurse is caring for a client with pneumonia. Which nursing intervention is thepriority? (Variation 2) (Which intervention is the priority?)A Encourage oral fluidsB.Obtaina sputumcultureC. Administer oxygen therapyD. Monitor temperatureCorrect Answer: C . Administer oxygen therapyRationale:Rationale: The correctansweraligns withnursing standards.C. Administer oxygentherapy is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway breathing, circulation) and Maslows hierarchy.Question 22: A nurse is caring for a client with heart failure who i s receiving furosemide.Which assessment finding requires immediate action? (Variation 16) (Select all that apply)A Potassium level of 3.0 mEq/LB. Blood pressure of 110/70 mmHgC. Heart rate of 80 bpmD. Reports of nauseaCorrect Answer: A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHg

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Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0mEq/L, B. Blood pressure of 110/70 mmHg is correct because it preventscomplications andensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) andMaslows hierarchy.Question 23: A nurse is caring for a client with heart failure who is receiving furosemide.Which assessment finding requires immediate action? (Variation 5)A Potassium level of 3.0 mEq/LB. Blood pressure of 110/70 mmHgC. Heart rate of 80 bpm□. Reports of nauseaCorrect Answer: A. Potassium level of 3.0 mEq/LRationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0mEq/L is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 24: A nurse i s assessing a client with chronic obstructive pulmonary disease(COPD). Which finding i s most concerning? (Variation 3)A Barrel-shaped chestB. Clubbing of fingersC. Oxygen saturation of 88%D. Respiratory rate of 22 breaths/minCorrect Answer: B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers iscorrect because it prevents complications and ensures safe client care. Nursing priorities follow theABCs (airway breathing, circulation) and Maslows hierarchy.Question 25: A nurse i s assessing a client with chronic obstructive pulmonary disease(COPD). Which finding is most concerning? (Variation 13) (Select all that apply)A Barrel-shaped chestB. Clubbing of fingersC. Oxygen saturation of 88%D. Respiratory rate of 22 breaths/minCorrect Answer: A. Barrel-shaped chest, B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. A. Barrel-shaped chest, B.Clubbing of fingers is correct because it prevents complications and ensures safe client care.Nursing priorities follow the ABCs (airway breathing, circulation) and Maslows hierarchy.Question 26: A nurse i s educating a client on warfarin therapy. Which statement indicates aneed for further teaching? (Variation 9} (Which intervention is the priority?)A 'I will avoid green leafy vegetables.'B. 'I will use an electric razor to shave.'

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C. 'I will take ibuprofen for headaches.'D. 'I will have regular blood tests to monitor my INR.'Correct Answer: C. 1 will take ibuprofen for headaches.'Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen forheadaches.’ is correct because it prevents complications and ensures safe client care. Nursingpriorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 27: A client with diabetes mellitus reports shakiness and confusion. The nurseshould first: (Variation 9)A. Check the clients blood glucoseB. Administer insulinC. Give a high-protein snackD. Encourage fluidsCorrect Answer: A. Check the client's blood glucoseRationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's bloodglucose is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 28: A nurse is assessing a client with chronic obstructivepulmonarydisease{COPD). Which finding is most concerning? (Variation 11) {Select all that apply)A Barrel-shaped chestB. Clubbing of fingersC. Oxygen saturation of 83%□. Respiratory rate of 22 breaths/minCorrect Answer: A. Barrel-shaped chest, B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. A. Barrel-shaped chest, B.Clubbing of fingers is correct because it prevents complications and ensures safe client care.Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 29: A nurse is caring for a client with pneumonia. Which nursing intervention is thepriority? (Variation 11) (Which task should the nurse delegate?)A Encourage oral fluidsB. Obtain a sputum cultureC. Administer oxygen therapyD. Monitor temperatureCorrect Answer: C . Administer oxygen therapyRationale:Rationale: The correctansweraligns withnursing standards.C. Administeroxygentherapy is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway, breathing, circulation) and Maslows hierarchy.Question 30: A nurseis assessing a client with chronic obstructivepulmonarydisease

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(COPD). Which finding is most concerning? (Variation 15)A. Barrel-shaped chestB. Clubbing of fingersC.Oxygensaturation of 88%D. Respiratory rate of 22 breaths/minCorrect Answer: B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers iscorrect because it prevents complications and ensures safe client care. Nursing priorities follow theABCs (airway, breathing, circulation) and Maslows hierarchy.Question31:A nurse is assessing a client with chronic obstructive pulmonary disease(COPD). Which finding is most concerning? (Variation 17) (Select all that apply)A Barrel-shaped chestB. Clubbing of fingersC. Oxygen saturation of 88%□. Respiratory rate of 22 breaths/minCorrect Answer: A. Barrel-shaped chest, B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. A. Barrel-shaped chest, B.Clubbing of fingers is correct because it prevents complications and ensures safe client care.Nursing priorities follow the ABCs (airway breathing, circulation) and Maslows hierarchy.Question 32: A nurse is assessing a client with chronic obstructive pulmonary disease(COPD).Which finding is most concerning? (Variation6)A Barrel-shaped chestB. Clubbing of fingersC. Oxygen saturation of 88%D. Respiratory rate of 22 breaths/minCorrect Answer: B. Clubbing of fingersRationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers iscorrect because it prevents complications and ensures safe client care. Nursing priorities follow theABCs (airway, breathing, circulation) and Maslows hierarchy.Question 33: A nurse is caring for a client with pneumonia. Which nursing intervention is thepriority? (Variation 1)A Encourage oral fluidsB. Obtain a sputum cultureC. Administer oxygen therapyD. Monitor temperatureCorrect Answer: C. Administer oxygen therapyRationale: Rationale: The correct answer aligns with nursing standards. C. Administeroxygentherapy is correct because it prevents complications and ensures safe client care. Nursing prioritiesfollow the ABCs (airway breathing, circulation) and Maslows hierarchy.

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