Florida NCLEX Comprehensive Review Practice Exam III
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1. A nurse is assessing a client admitted with suspected hypovolemic shock following
significant blood loss. Which assessment finding should the nurse recognize as the
earliest indicator of shock?
A. Decreased urine output
B. Hypotension
C. Tachycardia
D. Cyanosis
Answer: C. Tachycardia
Rationale: Tachycardia is the earliest compensatory response to hypovolemia. The body
increases heart rate to maintain cardiac output when circulating blood volume decreases.
Hypotension is a late finding that occurs after compensatory mechanisms begin to fail.
Decreased urine output results from reduced renal perfusion and occurs after
compensatory vasoconstriction. Cyanosis is a very late sign indicating severe tissue
hypoxia.
2. A client with heart failure is prescribed furosemide. Which laboratory value requires
immediate nursing intervention?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Calcium 9.4 mg/dL
D. Magnesium 2.0 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Loop diuretics such as furosemide commonly cause potassium loss. A
potassium level of 2.9 mEq/L is critically low and places the client at risk for life-threatening
,cardiac dysrhythmias and muscle weakness. Sodium, calcium, and magnesium values are
within normal limits.
3. A nurse is caring for a client experiencing acute chest pain. Which action should the
nurse perform first?
A. Administer prescribed morphine.
B. Obtain a 12-lead ECG.
C. Assess airway, breathing, and circulation.
D. Administer aspirin.
Answer: C. Assess airway, breathing, and circulation.
Rationale: The ABCs are always the priority in emergency care. After confirming that airway,
breathing, and circulation are stable, additional interventions such as obtaining an ECG,
administering aspirin, oxygen if indicated, nitroglycerin, or morphine can follow based on
the client's condition.
4. Which client has the highest priority for nursing assessment?
A. A client reporting mild nausea after lunch.
B. A postoperative client with a respiratory rate of 8 breaths/minute.
C. A client requesting pain medication rated 6/10.
D. A client awaiting discharge instructions.
Answer: B. A postoperative client with a respiratory rate of 8 breaths/minute.
Rationale: A respiratory rate of 8 breaths/minute indicates respiratory depression and
threatens oxygenation. Airway and breathing take priority over pain management, nausea,
or discharge planning.
5. Which assessment finding is most consistent with left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Crackles in both lungs
D. Hepatomegaly
Answer: C. Crackles in both lungs
, Rationale: Left-sided heart failure causes pulmonary congestion, resulting in crackles,
dyspnea, orthopnea, and pulmonary edema. Peripheral edema, jugular vein distention, and
hepatomegaly are more characteristic of right-sided heart failure.
6. A nurse is reinforcing teaching about insulin administration. Which statement by the
client indicates correct understanding?
A. "I will massage the injection site after giving insulin."
B. "I should rotate injection sites within the same anatomical area."
C. "I will inject insulin into scar tissue."
D. "I can reuse insulin needles until they become dull."
Answer: B. "I should rotate injection sites within the same anatomical area."
Rationale: Rotating injections within one anatomical area promotes consistent insulin
absorption while preventing lipodystrophy. Massaging injection sites may alter absorption.
Scar tissue impairs absorption, and needles should not be reused due to infection risk and
tissue trauma.
7. A client with chronic obstructive pulmonary disease is receiving oxygen at 2 L/min
via nasal cannula. The oxygen saturation is 90%. Which nursing action is most
appropriate?
A. Increase oxygen to 10 L/min.
B. Continue prescribed oxygen therapy and reassess.
C. Discontinue oxygen.
D. Apply a nonrebreather mask.
Answer: B. Continue prescribed oxygen therapy and reassess.
Rationale: Many clients with COPD have a target oxygen saturation between 88% and 92%.
Abruptly increasing oxygen concentrations may suppress respiratory drive in susceptible
individuals. The nurse should continue prescribed therapy, assess respiratory status, and
notify the provider if deterioration occurs.
8. Which laboratory value best evaluates long-term glucose control?
A. Random glucose
B. Fasting glucose
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 assessing a client admitted with suspected hypovolemic shock following
significant blood loss. Which assessment finding should the nurse recognize as the
earliest indicator of shock?
A. Decreased urine output
B. Hypotension
C. Tachycardia
D. Cyanosis
Answer: C. Tachycardia
Rationale: Tachycardia is the earliest compensatory response to hypovolemia. The body
increases heart rate to maintain cardiac output when circulating blood volume decreases.
Hypotension is a late finding that occurs after compensatory mechanisms begin to fail.
Decreased urine output results from reduced renal perfusion and occurs after
compensatory vasoconstriction. Cyanosis is a very late sign indicating severe tissue
hypoxia.
2. A client with heart failure is prescribed furosemide. Which laboratory value requires
immediate nursing intervention?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Calcium 9.4 mg/dL
D. Magnesium 2.0 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Loop diuretics such as furosemide commonly cause potassium loss. A
potassium level of 2.9 mEq/L is critically low and places the client at risk for life-threatening
,cardiac dysrhythmias and muscle weakness. Sodium, calcium, and magnesium values are
within normal limits.
3. A nurse is caring for a client experiencing acute chest pain. Which action should the
nurse perform first?
A. Administer prescribed morphine.
B. Obtain a 12-lead ECG.
C. Assess airway, breathing, and circulation.
D. Administer aspirin.
Answer: C. Assess airway, breathing, and circulation.
Rationale: The ABCs are always the priority in emergency care. After confirming that airway,
breathing, and circulation are stable, additional interventions such as obtaining an ECG,
administering aspirin, oxygen if indicated, nitroglycerin, or morphine can follow based on
the client's condition.
4. Which client has the highest priority for nursing assessment?
A. A client reporting mild nausea after lunch.
B. A postoperative client with a respiratory rate of 8 breaths/minute.
C. A client requesting pain medication rated 6/10.
D. A client awaiting discharge instructions.
Answer: B. A postoperative client with a respiratory rate of 8 breaths/minute.
Rationale: A respiratory rate of 8 breaths/minute indicates respiratory depression and
threatens oxygenation. Airway and breathing take priority over pain management, nausea,
or discharge planning.
5. Which assessment finding is most consistent with left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Crackles in both lungs
D. Hepatomegaly
Answer: C. Crackles in both lungs
, Rationale: Left-sided heart failure causes pulmonary congestion, resulting in crackles,
dyspnea, orthopnea, and pulmonary edema. Peripheral edema, jugular vein distention, and
hepatomegaly are more characteristic of right-sided heart failure.
6. A nurse is reinforcing teaching about insulin administration. Which statement by the
client indicates correct understanding?
A. "I will massage the injection site after giving insulin."
B. "I should rotate injection sites within the same anatomical area."
C. "I will inject insulin into scar tissue."
D. "I can reuse insulin needles until they become dull."
Answer: B. "I should rotate injection sites within the same anatomical area."
Rationale: Rotating injections within one anatomical area promotes consistent insulin
absorption while preventing lipodystrophy. Massaging injection sites may alter absorption.
Scar tissue impairs absorption, and needles should not be reused due to infection risk and
tissue trauma.
7. A client with chronic obstructive pulmonary disease is receiving oxygen at 2 L/min
via nasal cannula. The oxygen saturation is 90%. Which nursing action is most
appropriate?
A. Increase oxygen to 10 L/min.
B. Continue prescribed oxygen therapy and reassess.
C. Discontinue oxygen.
D. Apply a nonrebreather mask.
Answer: B. Continue prescribed oxygen therapy and reassess.
Rationale: Many clients with COPD have a target oxygen saturation between 88% and 92%.
Abruptly increasing oxygen concentrations may suppress respiratory drive in susceptible
individuals. The nurse should continue prescribed therapy, assess respiratory status, and
notify the provider if deterioration occurs.
8. Which laboratory value best evaluates long-term glucose control?
A. Random glucose
B. Fasting glucose
