NCLEX Success Academy, Prep & Practice Hub-RN & PN Support

A nurse is caring for a client with Type 1 Diabetes Mellitus who has been admitted with diabetic ketoacidosis (DKA). Which provider prescription should the nurse implement FIRST?

A. Administer regular insulin IV.

B. Initiate 0.9% normal saline IV infusion.

C. Administer potassium chloride IV.

D. Obtain a 12-lead ECG.

🤔 What’s your answer?

Use NCLEX strategies such as ABCs, Maslow’s Hierarchy, and Priority Nursing Interventions.

👇 Comment your answer and rationale below before checking the comments!

A nurse is caring for a client receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports chills, lower back pain, and shortness of breath.

What is the nurse’s FIRST action?

A. Slow the rate of the transfusion.

B. Stop the transfusion immediately.

C. Administer acetaminophen as prescribed.

D. Notify the healthcare provider.

🤔 What’s your answer?

💡 Apply the NCLEX principles of ABCs, patient safety, and priority nursing interventions.

👇 Comment your answer and rationale below before checking the comments

A nurse is caring for a client who is 24 hours post myocardial infarction (MI). Which finding requires immediate intervention?

A. Heart rate of 58 beats/min

B. Blood pressure of 146/88 mmHg

C. New onset of chest pain rated 8/10

D. Anxiety about returning home

🤔 What’s your answer?

Think about complications that can occur after an MI and use the ABCs, acute vs. chronic, and unstable vs. stable client principles.

Comment your answer and rationale below before checking the comments

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A nurse is caring for four clients in the emergency department. Which client should the nurse assess FIRST?

A. A client with a fractured wrist reporting pain of 9/10.

B. A client with asthma who is using accessory muscles to breathe and has audible wheezing.

C. A client with a temperature of 102.2°F (39°C) and a sore throat.

D. A client with nausea and vomiting for 24 hours.

🤔 What’s your answer?

💡 Apply the ABCs (Airway, Breathing, Circulation), Maslow’s Hierarchy, and NCLEX prioritization principles.

👇 Comment your answer and rationale below before checking the comments.

A nurse is caring for a client receiving a continuous heparin infusion. Which assessment finding requires immediate action?

A. Bruising at the IV insertion site

B. aPTT of 85 seconds

C. Heart rate of 88/min

D. Blood pressure of 128/76 mmHg

🤔 What’s your answer?

💡 Think about medication safety, adverse effects, and laboratory values. Which finding places the client at the greatest risk?

Comment your answer and rationale below before checking the comments.

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A nurse is caring for a client who is 8 hours postoperative following abdominal surgery. Which assessment finding requires immediate intervention?

A. Pain rated 7/10 at the surgical site

B. Temperature of 100.2°F (37.9°C)

C. Urine output of 20 mL over the last hour

D. Blood pressure of 138/84 mmHg

🤔 What’s your answer?

Use NCLEX strategies such as ABCs, Maslow’s Hierarchy, and recognizing signs of potential complications.

Comment your answer and rationale below before checking the comments

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A nurse is reviewing morning laboratory results for four clients. Which client should the nurse assess FIRST?

A. A client with heart failure who has a potassium level of 3.4 mEq/L.

B. A client with chronic kidney disease who has a potassium level of 6.2 mEq/L.

C. A client with diabetes mellitus who has a blood glucose level of 220 mg/dL.

D. A client with pneumonia who has a white blood cell count of 14,000/mm³.

🤔 Which client is the priority?

Use NCLEX strategies such as ABCs, Acute vs. Chronic, Expected vs. Unexpected Findings, and Potential for Life Threatening Complications.

👇 Comment your answer and rationale below before checking the comments!

A nurse receives report on four clients at the beginning of the shift. Which client should the nurse assess FIRST?

A. A client with COPD whose oxygen saturation is 90% on 2 L/min via nasal cannula.

B. A client who had abdominal surgery yesterday and reports pain of 8/10.

C. A client with a history of dementia who is suddenly confused and disoriented.

D. A client requesting assistance to the bathroom.

🤔 What’s your answer?

💡 Use NCLEX prioritization strategies such as ABCs, Maslow’s Hierarchy, Acute vs. Chronic, and Unexpected vs. Expected findings.

👇 Comment your answer and rationale below before checking the comments!

A nurse is assessing a client with hypoglycemia. Which finding requires immediate intervention?

A. Hunger
B. Sweating
C. Blood glucose 42 mg/dL and decreased level of consciousness
D. Tremors

🤔 What’s your answer?

Don’t just choose the option, explain your rationale using NCLEX strategies such as ABCs, Maslow’s Hierarchy, Safety and Risk Reduction, or Acute vs. Chronic.

Comment your answer below before checking the comments for the rationale.