Florida NCLEX Adult Medical-Surgical Nursing Practice Exam I
Updated Exam 2026 WITH Recent Newest Verified And Well Analyzed
Exam Questions (Actual Exam 2026-2027) Correct Detailed & Verified
ANSWERS (100% Accurate Solutions) ALREADY GRADED A+||NEWEST
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1. A nurse is caring for a client admitted with acute heart failure. Which assessment finding
requires immediate intervention?
A. Bilateral ankle edema
B. Weight gain of 2 lb (0.9 kg) in 24 hours
C. Crackles throughout both lung fields and oxygen saturation of 84%
D. Blood pressure of 146/88 mm Hg
Answer: C. Crackles throughout both lung fields and oxygen saturation of 84%
Rationale: Diffuse crackles accompanied by severe hypoxemia indicate pulmonary edema and
impaired gas exchange, making this the highest-priority finding. Immediate interventions
include administering oxygen, positioning the client upright, and notifying the provider while
preparing additional therapies. Although edema, mild weight gain, and moderately elevated
blood pressure require attention, they are not as immediately lifethreatening as respiratory
compromise.
2. A client with chronic kidney disease has a serum potassium level of 6.5 mEq/L.
Which nursing action is the priority?
A. Encourage oral fluids.
B. Place the client on continuous cardiac monitoring.
C. Restrict protein intake.
D. Obtain a urine specimen.
Answer: B. Place the client on continuous cardiac monitoring.
Rationale: Hyperkalemia significantly increases the risk of life-threatening cardiac dysrhythmias.
Continuous cardiac monitoring allows early detection of ECG changes while treatment is
initiated. Encouraging fluids may be contraindicated depending on renal function, and protein
restriction or urine collection does not address the immediate cardiac risk.
,3. Which assessment finding is most consistent with hypovolemic shock?
A. Bounding pulses and warm skin
B. Bradycardia and hypertension
C. Tachycardia, cool clammy skin, and hypotension
D. Hypertension and jugular venous distention
Answer: C. Tachycardia, cool clammy skin, and hypotension
Rationale: Hypovolemic shock results from decreased circulating blood volume.
Compensatory mechanisms produce tachycardia and peripheral vasoconstriction, leading to
cool, clammy skin and hypotension. The other options are inconsistent with the expected
physiological response to volume depletion.
4. A nurse is teaching a client prescribed warfarin. Which statement by the client indicates the
need for further teaching?
A. "I will use a soft toothbrush."
B. "I will report unusual bruising."
C. "I can take aspirin for headaches whenever needed."
D. "I will have my blood checked regularly."
Answer: C. "I can take aspirin for headaches whenever needed."
Rationale: Aspirin inhibits platelet function and significantly increases the risk of bleeding when
taken with warfarin. Clients should consult their healthcare provider before taking aspirin or
other medications. The remaining statements demonstrate appropriate understanding of
warfarin therapy.
5. Which intervention is most appropriate for preventing atelectasis after abdominal surgery?
A. Restrict oral fluids.
B. Encourage incentive spirometer use every hour while awake.
C. Maintain the client in a flat position.
D. Limit coughing because it increases pain.
Answer: B. Encourage incentive spirometer use every hour while awake.
Rationale: Frequent use of an incentive spirometer promotes alveolar expansion, improves
ventilation, and reduces the risk of postoperative atelectasis. Fluids should generally be
encouraged when appropriate, semi-Fowler positioning promotes lung expansion, and coughing
should be encouraged with splinting of the incision.
, 6. A client with diabetes mellitus becomes diaphoretic, confused, and shaky. What is the
nurse's priority action?
A. Administer regular insulin.
B. Check the client's blood glucose level.
C. Encourage exercise.
D. Restrict carbohydrate intake.
Answer: B. Check the client's blood glucose level.
Rationale: The client's symptoms strongly suggest hypoglycemia. Verifying the blood glucose
level guides prompt treatment. If hypoglycemia is confirmed and the client is conscious, a fast-
acting carbohydrate should be administered. Insulin would worsen hypoglycemia, and exercise
or carbohydrate restriction is inappropriate.
7. Which laboratory value should the nurse monitor most closely in a client receiving
intravenous unfractionated heparin?
A. Hemoglobin A1c
B. Activated partial thromboplastin time (aPTT)
C. Serum sodium
D. International normalized ratio (INR)
Answer: B. Activated partial thromboplastin time (aPTT)
Rationale: The aPTT is used to evaluate and adjust intravenous unfractionated heparin therapy
to maintain therapeutic anticoagulation while minimizing bleeding risk. INR is used primarily for
warfarin therapy, whereas hemoglobin A1c and sodium are unrelated to heparin dosing.
8. A client develops sudden unilateral weakness, facial drooping, and slurred speech.
What is the nurse's first action?
A. Offer oral fluids.
B. Activate the stroke response system immediately.
C. Place the client in Trendelenburg position.
D. Administer acetaminophen.
Answer: B. Activate the stroke response system immediately.
Updated Exam 2026 WITH Recent Newest Verified And Well Analyzed
Exam Questions (Actual Exam 2026-2027) Correct Detailed & Verified
ANSWERS (100% Accurate Solutions) ALREADY GRADED A+||NEWEST
VERSION Of The Exam Guarantee Pass!!
1. A nurse is caring for a client admitted with acute heart failure. Which assessment finding
requires immediate intervention?
A. Bilateral ankle edema
B. Weight gain of 2 lb (0.9 kg) in 24 hours
C. Crackles throughout both lung fields and oxygen saturation of 84%
D. Blood pressure of 146/88 mm Hg
Answer: C. Crackles throughout both lung fields and oxygen saturation of 84%
Rationale: Diffuse crackles accompanied by severe hypoxemia indicate pulmonary edema and
impaired gas exchange, making this the highest-priority finding. Immediate interventions
include administering oxygen, positioning the client upright, and notifying the provider while
preparing additional therapies. Although edema, mild weight gain, and moderately elevated
blood pressure require attention, they are not as immediately lifethreatening as respiratory
compromise.
2. A client with chronic kidney disease has a serum potassium level of 6.5 mEq/L.
Which nursing action is the priority?
A. Encourage oral fluids.
B. Place the client on continuous cardiac monitoring.
C. Restrict protein intake.
D. Obtain a urine specimen.
Answer: B. Place the client on continuous cardiac monitoring.
Rationale: Hyperkalemia significantly increases the risk of life-threatening cardiac dysrhythmias.
Continuous cardiac monitoring allows early detection of ECG changes while treatment is
initiated. Encouraging fluids may be contraindicated depending on renal function, and protein
restriction or urine collection does not address the immediate cardiac risk.
,3. Which assessment finding is most consistent with hypovolemic shock?
A. Bounding pulses and warm skin
B. Bradycardia and hypertension
C. Tachycardia, cool clammy skin, and hypotension
D. Hypertension and jugular venous distention
Answer: C. Tachycardia, cool clammy skin, and hypotension
Rationale: Hypovolemic shock results from decreased circulating blood volume.
Compensatory mechanisms produce tachycardia and peripheral vasoconstriction, leading to
cool, clammy skin and hypotension. The other options are inconsistent with the expected
physiological response to volume depletion.
4. A nurse is teaching a client prescribed warfarin. Which statement by the client indicates the
need for further teaching?
A. "I will use a soft toothbrush."
B. "I will report unusual bruising."
C. "I can take aspirin for headaches whenever needed."
D. "I will have my blood checked regularly."
Answer: C. "I can take aspirin for headaches whenever needed."
Rationale: Aspirin inhibits platelet function and significantly increases the risk of bleeding when
taken with warfarin. Clients should consult their healthcare provider before taking aspirin or
other medications. The remaining statements demonstrate appropriate understanding of
warfarin therapy.
5. Which intervention is most appropriate for preventing atelectasis after abdominal surgery?
A. Restrict oral fluids.
B. Encourage incentive spirometer use every hour while awake.
C. Maintain the client in a flat position.
D. Limit coughing because it increases pain.
Answer: B. Encourage incentive spirometer use every hour while awake.
Rationale: Frequent use of an incentive spirometer promotes alveolar expansion, improves
ventilation, and reduces the risk of postoperative atelectasis. Fluids should generally be
encouraged when appropriate, semi-Fowler positioning promotes lung expansion, and coughing
should be encouraged with splinting of the incision.
, 6. A client with diabetes mellitus becomes diaphoretic, confused, and shaky. What is the
nurse's priority action?
A. Administer regular insulin.
B. Check the client's blood glucose level.
C. Encourage exercise.
D. Restrict carbohydrate intake.
Answer: B. Check the client's blood glucose level.
Rationale: The client's symptoms strongly suggest hypoglycemia. Verifying the blood glucose
level guides prompt treatment. If hypoglycemia is confirmed and the client is conscious, a fast-
acting carbohydrate should be administered. Insulin would worsen hypoglycemia, and exercise
or carbohydrate restriction is inappropriate.
7. Which laboratory value should the nurse monitor most closely in a client receiving
intravenous unfractionated heparin?
A. Hemoglobin A1c
B. Activated partial thromboplastin time (aPTT)
C. Serum sodium
D. International normalized ratio (INR)
Answer: B. Activated partial thromboplastin time (aPTT)
Rationale: The aPTT is used to evaluate and adjust intravenous unfractionated heparin therapy
to maintain therapeutic anticoagulation while minimizing bleeding risk. INR is used primarily for
warfarin therapy, whereas hemoglobin A1c and sodium are unrelated to heparin dosing.
8. A client develops sudden unilateral weakness, facial drooping, and slurred speech.
What is the nurse's first action?
A. Offer oral fluids.
B. Activate the stroke response system immediately.
C. Place the client in Trendelenburg position.
D. Administer acetaminophen.
Answer: B. Activate the stroke response system immediately.
