NCLEX-RN EXAM PRACTICE QUESTIONS
WITH CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A |
INSTANT DOWNLOAD PDF
1. A nurse is caring for a client who suddenly develops severe shortness of
breath, chest pain, and an oxygen saturation of 84%. Which action should the
nurse take first?
A. Notify the healthcare provider
B. Apply oxygen and assess the client's airway and breathing
C. Administer oral fluids
D. Obtain a urine specimen
CORRECT ANSWER: B — Apply oxygen and assess the client's airway and breathing
RATIONALE: Using the ABC priority framework, airway and breathing take precedence.
Immediate oxygen administration and respiratory assessment are essential.
2. Which client should the nurse assess first?
A. A client with a serum potassium level of 6.9 mEq/L and peaked T waves
B. A client requesting pain medication for arthritis
C. A client awaiting discharge instructions
D. A client requesting assistance with bathing
CORRECT ANSWER: A — A client with a serum potassium level of 6.9 mEq/L and peaked
T waves
RATIONALE: Severe hyperkalemia with ECG changes places the client at immediate risk for
life-threatening cardiac dysrhythmias.
3. A nurse is caring for a client receiving packed red blood cells who develops
fever, chills, hypotension, and flank pain. What is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion immediately and maintain IV access with normal saline
,C. Administer acetaminophen and continue the transfusion
D. Reassure the client
CORRECT ANSWER: B — Stop the transfusion immediately and maintain IV access with
normal saline
RATIONALE: These findings indicate a possible acute hemolytic transfusion reaction requiring
immediate discontinuation of the transfusion.
4. A client receiving IV morphine becomes difficult to arouse and has a
respiratory rate of 7 breaths/minute. Which medication should the nurse prepare
to administer?
A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
CORRECT ANSWER: B — Naloxone
RATIONALE: Naloxone is the opioid antagonist used to reverse opioid-induced respiratory
depression.
5. A nurse is assessing a client who suddenly develops facial drooping, right arm
weakness, and slurred speech. Which nursing action has the highest priority?
A. Activate the stroke protocol and determine the last known well time
B. Encourage the client to rest
C. Offer oral fluids
D. Administer pain medication
CORRECT ANSWER: A — Activate the stroke protocol and determine the last known well
time
RATIONALE: Rapid identification and treatment of stroke improve eligibility for thrombolytic
therapy and reduce neurological damage.
6. Which assessment finding requires immediate intervention in a client receiving
magnesium sulfate?
, A. Respiratory rate of 8 breaths/minute
B. Blood pressure of 148/92 mmHg
C. Deep tendon reflexes of 2+
D. Urine output of 40 mL/hr
CORRECT ANSWER: A — Respiratory rate of 8 breaths/minute
RATIONALE: Respiratory depression is an early sign of magnesium toxicity and requires
immediate intervention.
7. A nurse is caring for a client with bacterial meningitis. Which intervention
should be implemented first?
A. Initiate droplet precautions immediately
B. Encourage visitors
C. Increase room lighting
D. Restrict fluid intake
CORRECT ANSWER: A — Initiate droplet precautions immediately
RATIONALE: Bacterial meningitis spreads through respiratory droplets, making isolation a
priority.
8. Which client has the highest priority for assessment?
A. A client with black, tarry stools, blood pressure of 84/50 mmHg, and dizziness
B. A client requesting assistance with breakfast
C. A client waiting for discharge medications
D. A client with chronic back pain
CORRECT ANSWER: A — A client with black, tarry stools, blood pressure of 84/50 mmHg,
and dizziness
RATIONALE: These findings indicate possible gastrointestinal hemorrhage with hypovolemic
shock.
9. A client receiving insulin becomes confused, diaphoretic, and shaky. Blood
glucose is 40 mg/dL. What should the nurse do first?
WITH CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A |
INSTANT DOWNLOAD PDF
1. A nurse is caring for a client who suddenly develops severe shortness of
breath, chest pain, and an oxygen saturation of 84%. Which action should the
nurse take first?
A. Notify the healthcare provider
B. Apply oxygen and assess the client's airway and breathing
C. Administer oral fluids
D. Obtain a urine specimen
CORRECT ANSWER: B — Apply oxygen and assess the client's airway and breathing
RATIONALE: Using the ABC priority framework, airway and breathing take precedence.
Immediate oxygen administration and respiratory assessment are essential.
2. Which client should the nurse assess first?
A. A client with a serum potassium level of 6.9 mEq/L and peaked T waves
B. A client requesting pain medication for arthritis
C. A client awaiting discharge instructions
D. A client requesting assistance with bathing
CORRECT ANSWER: A — A client with a serum potassium level of 6.9 mEq/L and peaked
T waves
RATIONALE: Severe hyperkalemia with ECG changes places the client at immediate risk for
life-threatening cardiac dysrhythmias.
3. A nurse is caring for a client receiving packed red blood cells who develops
fever, chills, hypotension, and flank pain. What is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion immediately and maintain IV access with normal saline
,C. Administer acetaminophen and continue the transfusion
D. Reassure the client
CORRECT ANSWER: B — Stop the transfusion immediately and maintain IV access with
normal saline
RATIONALE: These findings indicate a possible acute hemolytic transfusion reaction requiring
immediate discontinuation of the transfusion.
4. A client receiving IV morphine becomes difficult to arouse and has a
respiratory rate of 7 breaths/minute. Which medication should the nurse prepare
to administer?
A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
CORRECT ANSWER: B — Naloxone
RATIONALE: Naloxone is the opioid antagonist used to reverse opioid-induced respiratory
depression.
5. A nurse is assessing a client who suddenly develops facial drooping, right arm
weakness, and slurred speech. Which nursing action has the highest priority?
A. Activate the stroke protocol and determine the last known well time
B. Encourage the client to rest
C. Offer oral fluids
D. Administer pain medication
CORRECT ANSWER: A — Activate the stroke protocol and determine the last known well
time
RATIONALE: Rapid identification and treatment of stroke improve eligibility for thrombolytic
therapy and reduce neurological damage.
6. Which assessment finding requires immediate intervention in a client receiving
magnesium sulfate?
, A. Respiratory rate of 8 breaths/minute
B. Blood pressure of 148/92 mmHg
C. Deep tendon reflexes of 2+
D. Urine output of 40 mL/hr
CORRECT ANSWER: A — Respiratory rate of 8 breaths/minute
RATIONALE: Respiratory depression is an early sign of magnesium toxicity and requires
immediate intervention.
7. A nurse is caring for a client with bacterial meningitis. Which intervention
should be implemented first?
A. Initiate droplet precautions immediately
B. Encourage visitors
C. Increase room lighting
D. Restrict fluid intake
CORRECT ANSWER: A — Initiate droplet precautions immediately
RATIONALE: Bacterial meningitis spreads through respiratory droplets, making isolation a
priority.
8. Which client has the highest priority for assessment?
A. A client with black, tarry stools, blood pressure of 84/50 mmHg, and dizziness
B. A client requesting assistance with breakfast
C. A client waiting for discharge medications
D. A client with chronic back pain
CORRECT ANSWER: A — A client with black, tarry stools, blood pressure of 84/50 mmHg,
and dizziness
RATIONALE: These findings indicate possible gastrointestinal hemorrhage with hypovolemic
shock.
9. A client receiving insulin becomes confused, diaphoretic, and shaky. Blood
glucose is 40 mg/dL. What should the nurse do first?
