NCLEX-RN Sample Questions and Explanations

A UAP (such as a nursing assistant) can do routine, predictable tasks for clients who are stable. Taking vital signs on a stable client 2 days after surgery fits this rule. The RN still reviews the numbers and acts on anything abnormal.

A simple way to remember what the RN keeps: assessment, teaching, evaluation, and nursing judgment cannot be delegated to a UAP.

Wrong choices

• "Teaching a client how to use an incentive spirometer": Teaching is an RN responsibility. A UAP can remind a client to use it, but cannot do the teaching.
• "Completing the skin assessment": Assessment, especially on admission, needs nursing judgment and stays with the RN.
• "Giving a scheduled oral medication": Giving medications is outside the UAP role.

Newborns are born with low vitamin K, and their gut does not yet have the bacteria that make it. Vitamin K is needed for blood to clot. One injection soon after birth prevents vitamin K deficiency bleeding, a rare but serious bleeding problem that can affect the brain.

Wrong choices

• "It protects your baby's eyes from infection" describes the eye ointment (erythromycin), not vitamin K.
• "It helps lower the chance of newborn jaundice" is not correct. Jaundice is managed with feeding and, if needed, light therapy.
• "It protects your baby from hepatitis B" describes the hepatitis B vaccine, a different injection.

Lithium has a narrow safe range in the blood. Early signs of toxicity include nausea, vomiting, diarrhea, and a worsening hand tremor. Vomiting and diarrhea also cause fluid and sodium loss, which can raise the lithium level even more. The nurse should hold the dose and report the finding so the level can be checked.

Wrong choices

• "Feeling calmer than last week" is the expected effect of treatment.
• "Mild thirst when starting the medicine" is a common side effect, not a sign of toxicity on its own.
• "Increased appetite" can occur with lithium and is not a sign of toxicity.

Heparin is a high-alert blood thinner. When a client on heparin shows signs of serious bleeding, the drug is stopped and protamine sulfate may be given. Protamine binds to heparin in the blood and makes it inactive within minutes.

It helps to remember the pairs:

1. Heparin → protamine sulfate
2. Warfarin → vitamin K (phytonadione)
3. Opioids → naloxone
4. Benzodiazepines → flumazenil

Wrong choices

• "Vitamin K": this reverses warfarin, not heparin. It works slowly, over hours.
• "Naloxone": reverses opioids such as morphine. It has no effect on bleeding.
• "Flumazenil": reverses benzodiazepines such as lorazepam. It has no effect on bleeding.

Getting informed consent is the provider's job (the surgeon or the person doing the procedure). The provider explains the procedure, risks, benefits, and other options.

The nurse's role is to witness the signature. This means the nurse confirms that the person signing is the client, that the client signed of their own free will, and that the client appears able to make the decision. If the client has questions, the nurse contacts the provider.

Wrong choices

• "Explain the risks and benefits": This is the provider's duty, not the nurse's.
• "Decide whether the client truly needs the surgery": The nurse does not decide medical treatment.
• "Have the client's adult child sign": A competent adult signs their own consent. A family member signs only if the client cannot legally make the decision and that person is the legal decision-maker.

MMR is a live vaccine (it contains weakened live virus). Live vaccines are not given during pregnancy because of a possible risk to the baby. A client who is not immune to rubella is usually given MMR after the baby is born.

Wrong choices

• "Tdap" is an inactivated vaccine and is recommended during each pregnancy to protect the newborn from whooping cough.
• "Inactivated influenza (flu shot)" is recommended during pregnancy because flu can be serious for pregnant clients.
• "Hepatitis B" is not a live vaccine; certain hepatitis B vaccine brands are recommended during pregnancy for clients at risk.

An open-ended statement such as "Tell me more" invites the client to talk about the fear. This helps the nurse learn what the client is worried about (pain, anesthesia, results) and give the right support or information.

Wrong choices

• "Don't worry. Your surgeon is excellent" is false reassurance. It brushes off the client's feelings.
• "Why are you scared?" asks "why," which can make the client feel they must defend their feelings.
• "Everyone feels that way" generalizes and makes the client's feelings seem unimportant.

Warfarin slows the liver's use of vitamin K to make clotting factors. Its effect is measured with the prothrombin time (PT), reported as the INR (international normalized ratio). The INR lets results be compared between labs. The provider sets the target INR for each client, and the dose is adjusted to keep the client in that range.

An INR above the target means a higher bleeding risk. An INR below the target means the client is less protected from clots.

Wrong choices

• "aPTT": this is used to monitor IV heparin, not warfarin. Mixing up these two tests is a common error.
• "Platelet count": important to watch with heparin (for heparin-induced thrombocytopenia), but it does not show warfarin's effect.
• "Serum potassium": not related to warfarin's effect on clotting.

C. diff forms spores (a tough, protected form of the germ). Alcohol does not kill these spores well. Washing with soap and running water physically rubs and rinses them off the hands.

So for C. diff, the nurse wears gloves and a gown (contact precautions) and then washes hands with soap and water after care.

Wrong choices

• "Alcohol-based hand rub": Alcohol rub is fine for most germs but does not work well against C. diff spores.
• "Removing gloves without any hand hygiene": Hand hygiene is always needed after removing gloves; gloves can have tiny holes or contaminate hands while being removed.
• "Wiping hands with a disinfectant wipe for equipment": Equipment wipes are not made for skin and can harm it.

For a hands-on skill, the best way to check learning is a return demonstration: the client does the skill while the nurse watches. The nurse can see mistakes and correct them before the client goes home.

Wrong choices

• "Yes, I understand" does not prove the client can do the skill. Many people say yes even when they are unsure.
• "Takes home a printed handout" is a helpful extra but does not show the client can do it.
• "Watches a video about insulin" is a teaching method, not a way to check learning.