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Lippincott Style NCLEX Questions

Lippincott-style NCLEX practice questions with rationales covering critical nursing priorities like medication safety, lab interpretation, and patient education. Ideal for NCLEX-RN/PN prep with select-all-that-apply and scenario-based formats.

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    Lippincott-Style NCLEX Questions with Rationales Question 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/L B. Blood pressure of 110/70 mmHg C. Heart rate of 80 bpm D. Reports of nausea Correct Answer: A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHg Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHg is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 2: A nurse is educating a client on warfarin therapy. Which statement indicates a need 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 for headaches." is correct because it prevents complications and ensures safe client care. Nursing priorities 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.'L B. Blood pressure of 110/70 mmHg C. Heart rate of 80 bpm □ . Reports of nausea Correct Answer: A. Potassium level of 3.0 mEq/L Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0 mEq/L is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 4: A client with diabetes mellitus reports shakiness and confusion. The nurse should first: (Variation 1) (Select all that apply) A Check the client's blood glucose B. Administer insulin

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    C. Give a high-protein snack D. Encourage fluids Correct Answer: A. Check the client's blood glucose, B. Administer insulin Rationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's blood glucose, B. Administer insulin is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 5: A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding is most concerning? (Variation 5) A Barrel-shaped chest B. Clubbing of fingers C. Oxygen saturation of 88% D. Respiratory rate of 22 breaths, ''min Correct Answer: B. Clubbing of fingers Rationale: Rationale: The correct answer aligns with nursing standards. 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 6: A nurse is caring for a client with pneumonia. Which nursing intervention is the priority? (Variation 9) (Which intervention is the priority?) A Encourage oral fluids B. Obtain a sputum culture C. Administer oxygen therapy D. Monitor temperature Correct Answer: C. Administer oxygen therapy Rationale: Rationale: The correct answer aligns with nursing standards. C. Administer oxygen therapy is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 7: A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding is most concerning? (Variation 8) (Select all that apply) A Barrel-shaped chest B. Clubbing of fingers C. Oxygen saturation of 88% D. Respiratory rate of 22 breaths/min Correct Answer: A. Barrel-shaped chest, B. Clubbing of fingers Rationale: 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 will avoid green leafy vegetables. 1 B. 1 will use an electric razor to shave. 1 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. 1 will take ibuprofen for headaches.' is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 9: A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding is most concerning? (Variation 19) A Barrel-shaped chest B. Clubbing of fingers C. Oxygen saturation of 88% D. Respiratory rate of 22 breaths/min Correct Answer: B. Clubbing of fingers Rationale: Rationale: The correct answer aligns with nursing standards. 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 10: A nurse is educating a client on warfarin therapy. Which statement indicates a need for further teaching? (Variation 12} (Select all that apply) A ’I will avoid green leafy vegetables. 1 B. ’I will use an electric razor to shave. 1 C. ’I will take ibuprofen for headaches.' D. ’I will have regular blood tests to monitor my INR.' Correct Answer: A. 'I will avoid green leafy vegetables.', B. 'I will use an electric razor to shave.’ Rationale: Rationale: The correct answer aligns with nursing standards. A. 'I will avoid green leafy vegetables.’, B. 1 will use an electric razor to shave.’ is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 11: A client with diabetes mellitus reports shakiness and confusion. The nurse should first: (Variation 6) (Which intervention is the priority?) A Check the client’s blood glucose B. Administer insulin C. Give a high-protein snack D. Encourage fluids Correct 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 blood glucose is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslow r s 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/L B. Blood pressure of 110/70 mmHg C. Heart rate of 80 bpm D. Reports of nausea Correct Answer: A. Potassium level of 3.0 mEq/L Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0 mEq/L is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway breathing, circulation) and Maslows hierarchy. Question 13: A client with diabetes mellitus reports shakiness and confusion. The nurse should first: (Variation 15} (Select all that apply) A Check the client’s blood glucose B. Administer insulin C. Give a high-protein snack D. Encourage fluids Correct Answer: A. Check the client's blood glucose. B. Administer insulin Rationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's blood glucose, B. Administer insulin is correct because it prevents complications and ensures safe client care. 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 a need for further teaching? (Variation 13) A 'I will avoid green leafy vegetables.' B. ’I will use an electric razor to shave.' C. ’I will take ibuprofen for headaches.’ D. 'I will have regular blood tests to monitor my I NR.' Correct Answer: C. 'I will take ibuprofen for headaches.’ Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen for headaches.’ is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 15: A client with diabetes mellitus reports shakiness and confusion. The nurse should first: (Variation 20) (Which task should the nurse delegate?) A Check the client's blood glucose B. Administer insulin C. Give a high-protein snack

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    D. Encourage fluids Correct Answer: A. Check the client's blood glucose Rationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's blood glucose is correct because it prevents complications and ensures safe client care. Nursing priorities follow 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/L B. Blood pressure of 110/70 mmHg C. Heart rate of 80 bpm D. Reports of nausea Correct Answer: A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHg Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHg is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway breathing, circulation) and Maslows 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/L B. Blood pressure of 110/70 mmHg C. Heart rate of 80 bpm D. Reports of nausea Correct Answer: A. Potassium level of 3.0 mEq/L Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0 mEq/L is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway breathing, circulation) and Maslows hierarchy. Question 18: A nurse is educating a client on warfarin therapy. Which statement indicates a need for further teaching? (Variation?) A 'I will avoid green leafy vegetables.' B. 'I will use an electric razor to shave.' C. 'I will take ibuprofen for headaches.' D. 'I will have regular blood tests to monitor my I NR.' Correct Answer: C. 'I will take ibuprofen for headaches.' Rationale: Rationale: The correct answer aligns with nursing standards. C. 1 will take ibuprofen for headaches.' is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. 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. '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: A. ’I will avoid green leafy vegetables. 1 , B. 'I will use an electric razor to shave.' Rationale: Rationale: The correct answer aligns with nursing standards. A. ’I will avoid green leafy vegetables ', B. 'I will use an electric razor to shave.' is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation ) and Maslows hierarchy. Question 20: A nurse is educating □ client on warfarin therapy. Which statement indicates a need for further teaching? (Variation 17) A ’I will avoid green leafy vegetables.’ B. ’I will use an electric razor to shave.' C. 'I will take ibuprofen for headaches/ D. '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 for headaches/ is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 21: A nurse is caring for a client with pneumonia. Which nursing intervention is the priority? (Variation 2) (Which intervention is the priority?) A Encourage oral fluids B. Obtain a sputum culture C. Administer oxygen therapy D. Monitor temperature Correct Answer: C . Administer oxygen therapy Rationale: Rationale: The correct answer aligns with nursing standards. C. Administer oxygen therapy is correct because it prevents complications and ensures safe client care. Nursing priorities follow 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/L B. Blood pressure of 110/70 mmHg C. Heart rate of 80 bpm D. Reports of nausea Correct 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 3.0 mEq/L, B. Blood pressure of 110/70 mmHg is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows 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/L B. Blood pressure of 110/70 mmHg C. Heart rate of 80 bpm □ . Reports of nausea Correct Answer: A. Potassium level of 3.0 mEq/L Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0 mEq/L is correct because it prevents complications and ensures safe client care. Nursing priorities follow 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 chest B. Clubbing of fingers C. Oxygen saturation of 88% D. Respiratory rate of 22 breath s/min Correct Answer: B. Clubbing of fingers Rationale: Rationale: The correct answer aligns with nursing standards. 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 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 chest B. Clubbing of fingers C. Oxygen saturation of 88% D. Respiratory rate of 22 breath s/min Correct Answer: A. Barrel-shaped chest, B. Clubbing of fingers Rationale: 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 a need 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 for headaches.’ is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 27: A client with diabetes mellitus reports shakiness and confusion. The nurse should first: (Variation 9) A. Check the clients blood glucose B. Administer insulin C. Give a high-protein snack D. Encourage fluids Correct Answer: A. Check the client's blood glucose Rationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's blood glucose is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 28: A nurse is assessing a client with chronic obstructive pulmonary disease {COPD). Which finding is most concerning? (Variation 11) {Select all that apply) A Barrel-shaped chest B. Clubbing of fingers C. Oxygen saturation of 83% □ . Respiratory rate of 22 breath s/min Correct Answer: A. Barrel-shaped chest, B. Clubbing of fingers Rationale: 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 the priority? (Variation 11) (Which task should the nurse delegate?) A Encourage oral fluids B. Obtain a sputum culture C. Administer oxygen therapy D. Monitor temperature Correct Answer: C . Administer oxygen therapy Rationale: Rationale: The correct answer aligns with nursing standards. C. Administer oxygen therapy is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy. Question 30: A nurse is assessing a client with chronic obstructive pulmonary disease

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    (COPD). Which finding is most concerning? (Variation 15) A. Barrel-shaped chest B. Clubbing of fingers C. Oxygen saturation of 88% D. Respiratory rate of 22 breaths/min Correct Answer: B. Clubbing of fingers Rationale: Rationale: The correct answer aligns with nursing standards. 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 31: 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 chest B. Clubbing of fingers C. Oxygen saturation of 88% □ . Respiratory rate of 22 breath s/min Correct Answer: A. Barrel-shaped chest, B. Clubbing of fingers Rationale: 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? (Variation 6) A Barrel-shaped chest B. Clubbing of fingers C. Oxygen saturation of 88% D. Respiratory rate of 22 breaths/min Correct Answer: B. Clubbing of fingers Rationale: Rationale: The correct answer aligns with nursing standards. 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 33: A nurse is caring for a client with pneumonia. Which nursing intervention is the priority? (Variation 1) A Encourage oral fluids B. Obtain a sputum culture C. Administer oxygen therapy D. Monitor temperature Correct Answer: C. Administer oxygen therapy Rationale: Rationale: The correct answer aligns with nursing standards. C. Administer oxygen therapy is correct because it prevents complications and ensures safe client care. Nursing priorities follow the ABCs (airway breathing, circulation) and Maslows hierarchy.

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