NCLEX RN Comprehensive Practice
Exam 003 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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1. A nurse is caring for a client who has returned from a cardiac
catheterization via the right femoral artery. The client is on bed rest with
the affected leg extended. Which assessment finding requires the most
immediate action by the nurse?
A) The client reports a pain level of 3 on a 0 to 10 scale at the insertion site.
B) The dressing has a small amount of dried blood.
C) The right foot is pale and cool compared with the left foot.
D) The client’s oral temperature is 37.8°C (100°F).
C) The right foot is pale and cool compared with the left foot.
Rationale: Pale, cool skin in the affected extremity indicates impaired arterial
perfusion, which may signal arterial occlusion, hematoma, or thrombus
formation. This is a medical emergency requiring immediate intervention to
prevent tissue ischemia. Mild pain and a small amount of dried blood are
expected findings. A low-grade temperature may indicate infection but is not the
priority over vascular compromise.
2. The nurse is planning care for a client admitted with acute mania. Which is
the priority nursing intervention during the first days of hospitalization?
A) Schedule the client for group therapy sessions.
B) Provide frequent high-calorie finger foods and fluids.
C) Confront the client’s grandiose delusions directly.
D) Place the client in a private room at the end of the hall.
,B) Provide frequent high-calorie finger foods and fluids.
Rationale: Clients with acute mania often exhibit hyperactivity, distractibility,
and inability to sit still to eat, leading to dehydration and malnutrition.
Providing portable, high-calorie, easy-to-eat foods and fluids meets basic
physiological needs, which are the priority according to Maslow’s hierarchy.
Group therapy is overstimulating; confronting delusions is nontherapeutic; a
private room far from the nurses’ station may reduce necessary observation.
3. A client is receiving parenteral nutrition (PN) through a central venous
catheter. The PN solution infusing is 2 hours behind schedule. What action
should the nurse take?
A) Increase the infusion rate to catch up over the next hour.
B) Maintain the current infusion rate and monitor the client.
C) Administer the remaining volume as a bolus.
D) Discontinue the PN and flush the line with normal saline.
B) Maintain the current infusion rate and monitor the client.
Rationale: The rate of PN infusion should never be increased to “catch up”
because rapid infusion can cause hyperglycemia, hyperosmolar diuresis, and
fluid overload. The nurse should maintain the prescribed rate, assess blood
glucose, and report the delay if significant volume was missed. Bolus
administration is contraindicated. Discontinuing PN abruptly can cause rebound
hypoglycemia; the line should not be flushed with saline without an order.
4. A client at 28 weeks’ gestation is admitted with painless, bright red vaginal
bleeding. The abdomen is soft and nontender. What condition does the
nurse suspect?
A) Abruptio placentae
B) Placenta previa
C) Preterm labor
D) Uterine rupture
B) Placenta previa
,Rationale: Painless, bright red vaginal bleeding in the third trimester with a soft,
nontender uterus is the classic presentation of placenta previa, where the
placenta implants over the cervical os. Abruptio placentae presents with dark
red bleeding, abdominal rigidity, and severe pain. Preterm labor involves
contractions and cervical change. Uterine rupture is associated with severe pain,
loss of uterine contour, and fetal distress.
5. A nurse is preparing to administer digoxin to a client with heart failure. The
nurse notes that the client’s apical pulse is 58 beats/min and regular. Which
action should the nurse take?
A) Administer the medication and document the pulse rate.
B) Hold the medication and notify the health care provider.
C) Give half the prescribed dose.
D) Recheck the pulse in 30 minutes.
B) Hold the medication and notify the health care provider.
Rationale: Digoxin has a narrow therapeutic range and can cause bradycardia.
Standard practice for adults is to hold the dose if the apical pulse is less than 60
beats/min and notify the provider. The nurse cannot independently halve the
dose. Rechecking later delays necessary communication about a potential
adverse effect.
6. The nurse is caring for a client with chronic obstructive pulmonary disease
(COPD) receiving 2 L/min oxygen via nasal cannula. The client’s arterial
blood gas (ABG) results are pH 7.33, PaCO₂ 62 mm Hg, PaO₂ 58 mm Hg,
HCO₃⁻ 32 mEq/L. How does the nurse interpret these results?
A) Compensated metabolic alkalosis
B) Uncompensated respiratory acidosis
C) Partially compensated respiratory acidosis
D) Compensated respiratory alkalosis
C) Partially compensated respiratory acidosis
Rationale: The pH 7.33 is acidotic, PaCO₂ 62 is elevated (respiratory source of
acidosis), and HCO₃⁻ 32 is elevated indicating metabolic compensation. Because
, the pH remains outside normal range (7.35–7.45), compensation is partial. Full
compensation would bring pH into normal range.
7. A client with type 1 diabetes mellitus is found unconscious. The nurse
suspects hypoglycemia. Which action should the nurse take first?
A) Administer 50% dextrose intravenously.
B) Check the client’s blood glucose level.
C) Give glucagon intramuscularly.
D) Call the rapid response team immediately.
B) Check the client’s blood glucose level.
Rationale: Whenever possible, a blood glucose check should precede treatment
to confirm hypoglycemia and guide therapy. If a glucometer is immediately
available, this is the first step. If unable to obtain a reading, the nurse would
then treat for presumed hypoglycemia per protocol. Calling the rapid response
team is appropriate if the client does not respond to treatment, but assessment
comes first.
8. The nurse is conducting a postpartum assessment 12 hours after a vaginal
delivery. The fundus is palpated 2 cm above the umbilicus and deviated to
the right. What is the nurse’s priority action?
A) Notify the health care provider immediately.
B) Administer oxytocin as prescribed.
C) Massage the fundus until firm.
D) Assist the client to empty her bladder.
D) Assist the client to empty her bladder.
Rationale: A fundus that is above the umbilicus and deviated to the right
indicates a distended bladder, which displaces the uterus and prevents effective
contraction. Emptying the bladder allows the fundus to return to midline and
descend. Massage may be needed after emptying if the fundus remains boggy.
Notifying the provider is not the first action unless bleeding is excessive.
9. A nurse is reviewing the laboratory results for a client receiving warfarin.
The international normalized ratio (INR) is 5.2. Which medication does the
Exam 003 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. A nurse is caring for a client who has returned from a cardiac
catheterization via the right femoral artery. The client is on bed rest with
the affected leg extended. Which assessment finding requires the most
immediate action by the nurse?
A) The client reports a pain level of 3 on a 0 to 10 scale at the insertion site.
B) The dressing has a small amount of dried blood.
C) The right foot is pale and cool compared with the left foot.
D) The client’s oral temperature is 37.8°C (100°F).
C) The right foot is pale and cool compared with the left foot.
Rationale: Pale, cool skin in the affected extremity indicates impaired arterial
perfusion, which may signal arterial occlusion, hematoma, or thrombus
formation. This is a medical emergency requiring immediate intervention to
prevent tissue ischemia. Mild pain and a small amount of dried blood are
expected findings. A low-grade temperature may indicate infection but is not the
priority over vascular compromise.
2. The nurse is planning care for a client admitted with acute mania. Which is
the priority nursing intervention during the first days of hospitalization?
A) Schedule the client for group therapy sessions.
B) Provide frequent high-calorie finger foods and fluids.
C) Confront the client’s grandiose delusions directly.
D) Place the client in a private room at the end of the hall.
,B) Provide frequent high-calorie finger foods and fluids.
Rationale: Clients with acute mania often exhibit hyperactivity, distractibility,
and inability to sit still to eat, leading to dehydration and malnutrition.
Providing portable, high-calorie, easy-to-eat foods and fluids meets basic
physiological needs, which are the priority according to Maslow’s hierarchy.
Group therapy is overstimulating; confronting delusions is nontherapeutic; a
private room far from the nurses’ station may reduce necessary observation.
3. A client is receiving parenteral nutrition (PN) through a central venous
catheter. The PN solution infusing is 2 hours behind schedule. What action
should the nurse take?
A) Increase the infusion rate to catch up over the next hour.
B) Maintain the current infusion rate and monitor the client.
C) Administer the remaining volume as a bolus.
D) Discontinue the PN and flush the line with normal saline.
B) Maintain the current infusion rate and monitor the client.
Rationale: The rate of PN infusion should never be increased to “catch up”
because rapid infusion can cause hyperglycemia, hyperosmolar diuresis, and
fluid overload. The nurse should maintain the prescribed rate, assess blood
glucose, and report the delay if significant volume was missed. Bolus
administration is contraindicated. Discontinuing PN abruptly can cause rebound
hypoglycemia; the line should not be flushed with saline without an order.
4. A client at 28 weeks’ gestation is admitted with painless, bright red vaginal
bleeding. The abdomen is soft and nontender. What condition does the
nurse suspect?
A) Abruptio placentae
B) Placenta previa
C) Preterm labor
D) Uterine rupture
B) Placenta previa
,Rationale: Painless, bright red vaginal bleeding in the third trimester with a soft,
nontender uterus is the classic presentation of placenta previa, where the
placenta implants over the cervical os. Abruptio placentae presents with dark
red bleeding, abdominal rigidity, and severe pain. Preterm labor involves
contractions and cervical change. Uterine rupture is associated with severe pain,
loss of uterine contour, and fetal distress.
5. A nurse is preparing to administer digoxin to a client with heart failure. The
nurse notes that the client’s apical pulse is 58 beats/min and regular. Which
action should the nurse take?
A) Administer the medication and document the pulse rate.
B) Hold the medication and notify the health care provider.
C) Give half the prescribed dose.
D) Recheck the pulse in 30 minutes.
B) Hold the medication and notify the health care provider.
Rationale: Digoxin has a narrow therapeutic range and can cause bradycardia.
Standard practice for adults is to hold the dose if the apical pulse is less than 60
beats/min and notify the provider. The nurse cannot independently halve the
dose. Rechecking later delays necessary communication about a potential
adverse effect.
6. The nurse is caring for a client with chronic obstructive pulmonary disease
(COPD) receiving 2 L/min oxygen via nasal cannula. The client’s arterial
blood gas (ABG) results are pH 7.33, PaCO₂ 62 mm Hg, PaO₂ 58 mm Hg,
HCO₃⁻ 32 mEq/L. How does the nurse interpret these results?
A) Compensated metabolic alkalosis
B) Uncompensated respiratory acidosis
C) Partially compensated respiratory acidosis
D) Compensated respiratory alkalosis
C) Partially compensated respiratory acidosis
Rationale: The pH 7.33 is acidotic, PaCO₂ 62 is elevated (respiratory source of
acidosis), and HCO₃⁻ 32 is elevated indicating metabolic compensation. Because
, the pH remains outside normal range (7.35–7.45), compensation is partial. Full
compensation would bring pH into normal range.
7. A client with type 1 diabetes mellitus is found unconscious. The nurse
suspects hypoglycemia. Which action should the nurse take first?
A) Administer 50% dextrose intravenously.
B) Check the client’s blood glucose level.
C) Give glucagon intramuscularly.
D) Call the rapid response team immediately.
B) Check the client’s blood glucose level.
Rationale: Whenever possible, a blood glucose check should precede treatment
to confirm hypoglycemia and guide therapy. If a glucometer is immediately
available, this is the first step. If unable to obtain a reading, the nurse would
then treat for presumed hypoglycemia per protocol. Calling the rapid response
team is appropriate if the client does not respond to treatment, but assessment
comes first.
8. The nurse is conducting a postpartum assessment 12 hours after a vaginal
delivery. The fundus is palpated 2 cm above the umbilicus and deviated to
the right. What is the nurse’s priority action?
A) Notify the health care provider immediately.
B) Administer oxytocin as prescribed.
C) Massage the fundus until firm.
D) Assist the client to empty her bladder.
D) Assist the client to empty her bladder.
Rationale: A fundus that is above the umbilicus and deviated to the right
indicates a distended bladder, which displaces the uterus and prevents effective
contraction. Emptying the bladder allows the fundus to return to midline and
descend. Massage may be needed after emptying if the fundus remains boggy.
Notifying the provider is not the first action unless bleeding is excessive.
9. A nurse is reviewing the laboratory results for a client receiving warfarin.
The international normalized ratio (INR) is 5.2. Which medication does the
