2021 NCLEX LIVE-REVIEW QUESTIONS (PDATED 2023) 100% CORRECT & VERIFIED

1- A nurse admits a client who sustained C3 spinal cord injury. Which finding should the nurse recognize as priority of care? a) Heart rate b) Respirations 10/min c) Temperature 97 F (36 C) d) Blood pressure 88/54 mmHg 2- A nurse prepares an older adult for a scheduled colonoscopy. Which should be the nurse’s initial action? a) Chill bowel cleansing solution b) Monitor frequency of elimination c) Provide oral intake of clear liquids d) Place portable commode at bedside. 3- A client presents to the emergency department (ED) and reports a history of Gravida 3 Para 2. Which should be the nurse’s initial action after observing a presenting part? A) Provide emotional support to the client B) Notify labor and delivery staff members. C) Time frequency and duration of contractions D) Prepare for delivery of the newborn in the emergency department 4- A nurse enters the room of a client who is at the foot of the bed lying on the floor. Which should be the initial nursing action? a) Examine the client’s injuries. b) Obtain pulse and blood pressure c) Assess vital signs and level of consciousness d) Determine intensity of pain with range of motion. 5- Four days after a ventral hernia repair, a client who is obese and has history of COPD vomits and reports severe abdominal pain. The oxygen saturation is 90%. Which action should the nurse implement first? a) Administer ondansetron hcl IV. b) Encourage pursed lip breathing c) Assess the surgical incision site d) Apply low dose oxygen via nasal canula 6- A nurse provides care for a client who is 24 hors post-acute myocardial infarction and reports “I can’t breathe now that I am lying down after lunch”. Which should be the nurse’s initial action? a) Administer IV furosemide b) Place client in high-fowler’s position c) Begin oxygen 4-6L/min by nasal cannula d) Auscultate anterior and posterior lungs bilaterally 7- A nurse arrives at a work site explosion. Which client should the nurse triage first? a) Fixed pupils and agonal respirations b) Burns to the face and respiratory stridor c) Type 2 diabetes mellitus who is disoriented d) A closed fracture reporting “a pain level of 3” 8- A nurse is coordinating client care. Which client should the nurse delegate to the PN? A client who: a) Requires insertion of an indwelling urinary catheter. b) Has a new prescription for patient-controlled analgesia c) Has a tension pneumothorax and requires a chest tube? d) Requires intermittent suctioning of a new placed tracheostomy. 9- An adolescent client was admitted 12 hrs ago following a motor vehicle crash. Multiple skeletal fractures were sustained. The client is in balanced-suspension traction. Which assessment finding requires immediate intervention by the nurse? a) Disorientation b) Shallow respirations c) Chest pain with positioning d) Bloody drainage at the pin site. 10- A nurse provides care for a client who is scheduled for electroconvulsive therapy (ECT). Which medication should the nurse withhold prior to therapy? a) Atropine sulfate b) Phenytoin c) Methohexital d) Succinylcholine 11- A home health nurse is performing an admission assessment on a client who had a knee arthroplasty one week ago. Which client statements should concern the nurse the most? a) “I am so glad to be off those blood thinners” b) “I will keep a pillow under my knee when I am in bed “ c) “I am planning to use a wheelchair to help me get around” d) “I plan to take ibuprofen instead of the prescribed hydrocodone with acetaminophen for pain control” 12- A client has no voided eight hours following the removal of an indwelling bladder catheter. Which should be the nurse’s initial action? a) increase fluids b) perform bladder scan c) place indwelling catheter d) provide assistance to the bathroom 13- A nurse provides care for a client who has a chest tube. The nurse notes the chest tube has become disconnected from the chest drainage system. Which action should the nurse take? a) Increase the suction to the chest drainage system. b) Reposition the client to a high-fowler’s position c) Apply to the client low-flow oxygen via nasal cannula. d) Immerse the end of the chest tube in a bottler of sterile water 14- When an older adult die from complications of a cerebrovascular accident (CVA), the client ‘s partner is present the bedside. Which action should the nurse take? a) Give the partner time alone b) Stay with the partner at the bedside c) Ask the chaplain to come be with the partner d) Escort the partner to the hallway outside the room 15- A client who has just been diagnoses with rheumatoid arthritis is required to receive 3 months of methotrexate therapy. The nurse recognizes which of the following are adverse effects associated with the therapy? SATA a) WBC 1,200 mm3 b) Platelets 5,000 mm3 c) Weight gain 2.27 kg (5lb) d) Urine specific gravity 1,003 e) Oral temperature of 37.2 C (99 F)