NCLEX RN Comprehensive Practice
Exam 002 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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QUESTION 1
A 68 year old male patient is admitted to the medical surgical unit with a diagnosis
of exacerbation of chronic obstructive pulmonary disease. The nurse notes that
the patient has a barrel chest, uses accessory muscles to breathe, and has a
productive cough with thick green sputum. Which arterial blood gas value would
the nurse expect to see in this patient?
A. pH 7.32, PaCO2 58 mm Hg, HCO3 30 mEq/L, PaO2 70 mm Hg
B. pH 7.48, PaCO2 30 mm Hg, HCO3 22 mEq/L, PaO2 85 mm Hg
C. pH 7.38, PaCO2 42 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg
D. pH 7.52, PaCO2 48 mm Hg, HCO3 32 mEq/L, PaO2 68 mm Hg
Answer: A
Rationale: The patient with chronic obstructive pulmonary disease typically has
chronic hypercapnia due to alveolar hypoventilation. The kidneys compensate by
retaining bicarbonate, leading to a partially compensated respiratory acidosis.
Option A shows a low pH (acidosis), elevated PaCO2 (respiratory acidosis),
elevated bicarbonate (metabolic compensation), and low PaO2 (hypoxemia),
which is consistent with acute exacerbation of COPD. Option B shows respiratory
alkalosis, which would not be expected. Option C shows normal values. Option D
,shows metabolic alkalosis with respiratory acidosis, which is not consistent with
COPD exacerbation.
QUESTION 2
A 45 year old female patient is receiving IV heparin therapy for deep vein
thrombosis. The nurse is monitoring the patient's laboratory values. Which
laboratory value would indicate that the heparin therapy is at a therapeutic level?
A. aPTT of 65 seconds
B. INR of 2.5
C. Platelet count of 150,000/mm3
D. PT of 18 seconds
Answer: A
Rationale: The therapeutic range for heparin therapy is typically an aPTT
(activated partial thromboplastin time) that is 1.5 to 2.5 times the normal
control value. Normal aPTT is approximately 30-40 seconds, so a value of 65
seconds (approximately 2 times normal) indicates therapeutic anticoagulation.
INR is used to monitor warfarin therapy, not heparin. Platelet count monitoring
is important for heparin-induced thrombocytopenia but does not indicate
therapeutic level. PT is used to monitor warfarin therapy.
QUESTION 3
A patient with heart failure is prescribed furosemide 40 mg IV push. The nurse
should monitor the patient for which potential adverse effect?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypernatremia
Answer: C
,Rationale: Furosemide is a loop diuretic that inhibits sodium and chloride
reabsorption in the ascending loop of Henle. It causes significant potassium
wasting, leading to hypokalemia. Other adverse effects include hypocalcemia,
hyponatremia, hypomagnesemia, and dehydration. The nurse should monitor
serum electrolytes, especially potassium, and assess for signs of hypokalemia
such as muscle weakness, cardiac arrhythmias, and fatigue.
QUESTION 4
The nurse is caring for a patient who is 2 days post-operative following abdominal
surgery. The patient reports sudden onset of chest pain and shortness of breath.
The nurse notes that the patient's oxygen saturation is 88% on room air. Which
action should the nurse take first?
A. Administer oxygen via nasal cannula
B. Notify the healthcare provider
C. Prepare for a chest x-ray
D. Administer morphine sulfate for pain
Answer: A
Rationale: The patient is exhibiting signs of a possible pulmonary embolism,
which is a life-threatening complication following surgery. The priority action is
to address the patient's oxygenation and respiratory status. The nurse should
first administer oxygen to improve oxygen saturation and then notify the
healthcare provider. While morphine may be given for pain, it is not the first
action. A chest x-ray would be ordered by the provider, but the immediate
priority is oxygenation.
QUESTION 5
A 72 year old patient with Alzheimer's disease is becoming increasingly agitated
and is pacing in the hallway. The patient is at risk for falls. Which intervention
should the nurse implement first?
, A. Apply a vest restraint to prevent injury
B. Administer a PRN dose of haloperidol
C. Provide a structured environment with calming activities
D. Place the patient in a seclusion room
Answer: C
Rationale: The least restrictive interventions should be attempted first. Providing
a structured environment with calming activities addresses the patient's
agitation without using restraints or chemical sedation. Restraints should only
be used as a last resort when all other interventions have failed and the patient
is at immediate risk of harm. Chemical restraints should also be used cautiously
and only after non-pharmacological interventions have been attempted.
QUESTION 6
The nurse is preparing to administer a blood transfusion to a patient with anemia.
Which action is most important for the nurse to take prior to initiating the
transfusion?
A. Ensure that the patient has signed a consent form
B. Verify the patient's blood type and crossmatch with the blood product
C. Assess the patient's vital signs
D. Prime the IV tubing with normal saline
Answer: B
Rationale: Verification of the patient's blood type and crossmatch with the blood
product is the most critical action to prevent a potentially fatal hemolytic
transfusion reaction. This involves two licensed personnel checking the blood
product label against the patient's identification band and blood bank
documentation. While all options are important, verifying the blood type
compatibility is the priority safety measure.
Exam 002 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
QUESTION 1
A 68 year old male patient is admitted to the medical surgical unit with a diagnosis
of exacerbation of chronic obstructive pulmonary disease. The nurse notes that
the patient has a barrel chest, uses accessory muscles to breathe, and has a
productive cough with thick green sputum. Which arterial blood gas value would
the nurse expect to see in this patient?
A. pH 7.32, PaCO2 58 mm Hg, HCO3 30 mEq/L, PaO2 70 mm Hg
B. pH 7.48, PaCO2 30 mm Hg, HCO3 22 mEq/L, PaO2 85 mm Hg
C. pH 7.38, PaCO2 42 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg
D. pH 7.52, PaCO2 48 mm Hg, HCO3 32 mEq/L, PaO2 68 mm Hg
Answer: A
Rationale: The patient with chronic obstructive pulmonary disease typically has
chronic hypercapnia due to alveolar hypoventilation. The kidneys compensate by
retaining bicarbonate, leading to a partially compensated respiratory acidosis.
Option A shows a low pH (acidosis), elevated PaCO2 (respiratory acidosis),
elevated bicarbonate (metabolic compensation), and low PaO2 (hypoxemia),
which is consistent with acute exacerbation of COPD. Option B shows respiratory
alkalosis, which would not be expected. Option C shows normal values. Option D
,shows metabolic alkalosis with respiratory acidosis, which is not consistent with
COPD exacerbation.
QUESTION 2
A 45 year old female patient is receiving IV heparin therapy for deep vein
thrombosis. The nurse is monitoring the patient's laboratory values. Which
laboratory value would indicate that the heparin therapy is at a therapeutic level?
A. aPTT of 65 seconds
B. INR of 2.5
C. Platelet count of 150,000/mm3
D. PT of 18 seconds
Answer: A
Rationale: The therapeutic range for heparin therapy is typically an aPTT
(activated partial thromboplastin time) that is 1.5 to 2.5 times the normal
control value. Normal aPTT is approximately 30-40 seconds, so a value of 65
seconds (approximately 2 times normal) indicates therapeutic anticoagulation.
INR is used to monitor warfarin therapy, not heparin. Platelet count monitoring
is important for heparin-induced thrombocytopenia but does not indicate
therapeutic level. PT is used to monitor warfarin therapy.
QUESTION 3
A patient with heart failure is prescribed furosemide 40 mg IV push. The nurse
should monitor the patient for which potential adverse effect?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypernatremia
Answer: C
,Rationale: Furosemide is a loop diuretic that inhibits sodium and chloride
reabsorption in the ascending loop of Henle. It causes significant potassium
wasting, leading to hypokalemia. Other adverse effects include hypocalcemia,
hyponatremia, hypomagnesemia, and dehydration. The nurse should monitor
serum electrolytes, especially potassium, and assess for signs of hypokalemia
such as muscle weakness, cardiac arrhythmias, and fatigue.
QUESTION 4
The nurse is caring for a patient who is 2 days post-operative following abdominal
surgery. The patient reports sudden onset of chest pain and shortness of breath.
The nurse notes that the patient's oxygen saturation is 88% on room air. Which
action should the nurse take first?
A. Administer oxygen via nasal cannula
B. Notify the healthcare provider
C. Prepare for a chest x-ray
D. Administer morphine sulfate for pain
Answer: A
Rationale: The patient is exhibiting signs of a possible pulmonary embolism,
which is a life-threatening complication following surgery. The priority action is
to address the patient's oxygenation and respiratory status. The nurse should
first administer oxygen to improve oxygen saturation and then notify the
healthcare provider. While morphine may be given for pain, it is not the first
action. A chest x-ray would be ordered by the provider, but the immediate
priority is oxygenation.
QUESTION 5
A 72 year old patient with Alzheimer's disease is becoming increasingly agitated
and is pacing in the hallway. The patient is at risk for falls. Which intervention
should the nurse implement first?
, A. Apply a vest restraint to prevent injury
B. Administer a PRN dose of haloperidol
C. Provide a structured environment with calming activities
D. Place the patient in a seclusion room
Answer: C
Rationale: The least restrictive interventions should be attempted first. Providing
a structured environment with calming activities addresses the patient's
agitation without using restraints or chemical sedation. Restraints should only
be used as a last resort when all other interventions have failed and the patient
is at immediate risk of harm. Chemical restraints should also be used cautiously
and only after non-pharmacological interventions have been attempted.
QUESTION 6
The nurse is preparing to administer a blood transfusion to a patient with anemia.
Which action is most important for the nurse to take prior to initiating the
transfusion?
A. Ensure that the patient has signed a consent form
B. Verify the patient's blood type and crossmatch with the blood product
C. Assess the patient's vital signs
D. Prime the IV tubing with normal saline
Answer: B
Rationale: Verification of the patient's blood type and crossmatch with the blood
product is the most critical action to prevent a potentially fatal hemolytic
transfusion reaction. This involves two licensed personnel checking the blood
product label against the patient's identification band and blood bank
documentation. While all options are important, verifying the blood type
compatibility is the priority safety measure.
