Florida NCLEX Comprehensive Review Practice Exam II
Updated Exam 2026WITH Recent Newest Verified And Well
Analyzed Exam Questions (Actual Exam 2026-2027) Correct
Detailed &Verified ANSWERS (100% Accurate Solutions)
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1. A nurse is caring for a client with heart failure who suddenly develops crackles
throughout both lung fields and pink, frothy sputum. What is the nurse's priority
action?
A. Encourage oral fluids
B. Place the client in high-Fowler's position
C. Obtain a sputum specimen
D. Restrict sodium intake
Answer: B. Place the client in high-Fowler's position
Rationale: Acute pulmonary edema is a life-threatening complication of heart failure.
Positioning the client upright reduces venous return to the heart, improves lung expansion,
and enhances oxygenation. Additional interventions include administering oxygen and
prescribed diuretics, but positioning is the immediate nursing action.
2. A nurse is assessing a client suspected of having bacterial meningitis. Which
assessment finding requires immediate intervention?
A. Mild headache
B. Photophobia
C. Nuchal rigidity with decreased level of consciousness
D. Low-grade fever
Answer: C. Nuchal rigidity with decreased level of consciousness
Rationale: Decreased level of consciousness indicates worsening neurological function
and possible increased intracranial pressure. Prompt intervention is essential to prevent
permanent neurological damage or death. Although headache, fever, and photophobia are
common symptoms, altered mental status is the highest priority.
, 3. A client receiving warfarin therapy asks why routine blood testing is necessary. The
nurse explains that the test primarily evaluates:
A. Platelet count
B. Activated partial thromboplastin time (aPTT)
C. International normalized ratio (INR)
D. Bleeding time
Answer: C. International normalized ratio (INR)
Rationale: Warfarin therapy is monitored using the INR, which standardizes prothrombin
time results. The therapeutic range for most indications is generally between 2.0 and 3.0.
Maintaining the INR within the prescribed range reduces the risk of bleeding while ensuring
adequate anticoagulation.
4. Which client should the nurse assess first?
A. A client with chronic arthritis reporting pain rated 6/10
B. A postoperative client with oxygen saturation of 88%
C. A client awaiting discharge instructions
D. A client requesting assistance to the bathroom
Answer: B. A postoperative client with oxygen saturation of 88%
Rationale: Airway and breathing are the highest priorities according to the ABC framework.
Oxygen saturation below normal suggests impaired oxygenation and requires immediate
assessment and intervention before addressing less urgent concerns.
5. Which electrolyte imbalance is most commonly associated with peaked T waves on
an electrocardiogram?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Answer: B. Hyperkalemia
, Rationale: Hyperkalemia commonly produces tall, peaked T waves, widened QRS
complexes, and potentially fatal dysrhythmias. Early recognition allows prompt treatment
to prevent cardiac arrest.
6. A nurse is teaching a client with chronic kidney disease about dietary restrictions.
Which food should the client avoid because of its high potassium content?
A. White rice
B. Apples
C. Bananas
D. Bread
Answer: C. Bananas
Rationale: Bananas are rich in potassium. Clients with impaired kidney function have
difficulty excreting potassium, increasing the risk for hyperkalemia and cardiac
complications.
7. Which intervention best reduces the risk of ventilator-associated pneumonia?
A. Maintaining the client flat in bed
B. Performing oral care regularly
C. Restricting fluid intake
D. Limiting suctioning
Answer: B. Performing oral care regularly
Rationale: Frequent oral hygiene reduces bacterial colonization in the mouth, thereby
decreasing the risk of ventilator-associated pneumonia. Elevating the head of the bed is
another key preventive measure.
8. A nurse is caring for a client experiencing hypoglycemia. Which symptom should the
nurse expect first?
A. Fruity breath odor
B. Warm, dry skin
C. Diaphoresis and tremors
D. Kussmaul respirations
Updated Exam 2026WITH 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 with heart failure who suddenly develops crackles
throughout both lung fields and pink, frothy sputum. What is the nurse's priority
action?
A. Encourage oral fluids
B. Place the client in high-Fowler's position
C. Obtain a sputum specimen
D. Restrict sodium intake
Answer: B. Place the client in high-Fowler's position
Rationale: Acute pulmonary edema is a life-threatening complication of heart failure.
Positioning the client upright reduces venous return to the heart, improves lung expansion,
and enhances oxygenation. Additional interventions include administering oxygen and
prescribed diuretics, but positioning is the immediate nursing action.
2. A nurse is assessing a client suspected of having bacterial meningitis. Which
assessment finding requires immediate intervention?
A. Mild headache
B. Photophobia
C. Nuchal rigidity with decreased level of consciousness
D. Low-grade fever
Answer: C. Nuchal rigidity with decreased level of consciousness
Rationale: Decreased level of consciousness indicates worsening neurological function
and possible increased intracranial pressure. Prompt intervention is essential to prevent
permanent neurological damage or death. Although headache, fever, and photophobia are
common symptoms, altered mental status is the highest priority.
, 3. A client receiving warfarin therapy asks why routine blood testing is necessary. The
nurse explains that the test primarily evaluates:
A. Platelet count
B. Activated partial thromboplastin time (aPTT)
C. International normalized ratio (INR)
D. Bleeding time
Answer: C. International normalized ratio (INR)
Rationale: Warfarin therapy is monitored using the INR, which standardizes prothrombin
time results. The therapeutic range for most indications is generally between 2.0 and 3.0.
Maintaining the INR within the prescribed range reduces the risk of bleeding while ensuring
adequate anticoagulation.
4. Which client should the nurse assess first?
A. A client with chronic arthritis reporting pain rated 6/10
B. A postoperative client with oxygen saturation of 88%
C. A client awaiting discharge instructions
D. A client requesting assistance to the bathroom
Answer: B. A postoperative client with oxygen saturation of 88%
Rationale: Airway and breathing are the highest priorities according to the ABC framework.
Oxygen saturation below normal suggests impaired oxygenation and requires immediate
assessment and intervention before addressing less urgent concerns.
5. Which electrolyte imbalance is most commonly associated with peaked T waves on
an electrocardiogram?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Answer: B. Hyperkalemia
, Rationale: Hyperkalemia commonly produces tall, peaked T waves, widened QRS
complexes, and potentially fatal dysrhythmias. Early recognition allows prompt treatment
to prevent cardiac arrest.
6. A nurse is teaching a client with chronic kidney disease about dietary restrictions.
Which food should the client avoid because of its high potassium content?
A. White rice
B. Apples
C. Bananas
D. Bread
Answer: C. Bananas
Rationale: Bananas are rich in potassium. Clients with impaired kidney function have
difficulty excreting potassium, increasing the risk for hyperkalemia and cardiac
complications.
7. Which intervention best reduces the risk of ventilator-associated pneumonia?
A. Maintaining the client flat in bed
B. Performing oral care regularly
C. Restricting fluid intake
D. Limiting suctioning
Answer: B. Performing oral care regularly
Rationale: Frequent oral hygiene reduces bacterial colonization in the mouth, thereby
decreasing the risk of ventilator-associated pneumonia. Elevating the head of the bed is
another key preventive measure.
8. A nurse is caring for a client experiencing hypoglycemia. Which symptom should the
nurse expect first?
A. Fruity breath odor
B. Warm, dry skin
C. Diaphoresis and tremors
D. Kussmaul respirations
