NCLEX RN Comprehensive Practice
Exam 001 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
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1. A nurse is caring for a client who has just returned from surgery.
Which assessment finding requires immediate intervention?
A. Pain rated 6/10
B. Urine output of 35 mL/hr
C. Oxygen saturation of 88%
D. Temperature of 37.4°C (99.3°F)
Answer: C. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and
requires immediate assessment and intervention. Airway and
breathing take priority according to the ABCs.
2. A nurse is preparing to administer oral medications to a client.
Which action is most appropriate?
A. Leave the medications at the bedside
B. Verify the client's identity using two identifiers
C. Ask the roommate to identify the client
D. Administer medications based only on the room number
Answer: B. Verify the client's identity using two identifiers
,Rationale: Using two approved client identifiers helps prevent
medication errors. Room number should never be used as an
identifier.
3. A client with heart failure reports increasing shortness of breath.
Which position should the nurse place the client in?
A. Supine
B. Prone
C. High-Fowler's
D. Trendelenburg
Answer: C. High-Fowler's
Rationale: High-Fowler's positioning promotes lung expansion and
decreases venous return, which can reduce pulmonary congestion and
improve breathing.
4. A nurse is caring for a client receiving a blood transfusion. Which
finding requires immediate action?
A. Temperature of 37°C (98.6°F)
B. Mild thirst
C. Chills and low back pain
D. Heart rate of 78/min
Answer: C. Chills and low back pain
Rationale: Chills and low back pain can indicate an acute hemolytic
transfusion reaction. The nurse should stop the transfusion
immediately and follow the facility's transfusion-reaction protocol.
5. Which intervention is most appropriate for preventing pressure
injuries in an immobile client?
A. Massage reddened areas
B. Reposition the client regularly
,C. Keep the head of bed elevated at all times
D. Use a donut-shaped cushion under the sacrum
Answer: B. Reposition the client regularly
Rationale: Regular repositioning relieves prolonged pressure and
helps prevent tissue injury. Massage of reddened areas can cause
additional tissue damage.
6. A client taking warfarin should be monitored primarily using
which laboratory test?
A. INR
B. aPTT
C. Troponin
D. Hemoglobin A1c
Answer: A. INR
Rationale: The international normalized ratio (INR) is used to monitor
the therapeutic effect of warfarin and guide dosing.
7. A client receiving heparin develops bleeding from the gums.
Which medication should the nurse anticipate administering for
severe heparin-associated bleeding?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Acetylcysteine
Answer: B. Protamine sulfate
Rationale: Protamine sulfate reverses the anticoagulant effects of
unfractionated heparin. Vitamin K is used to reverse warfarin.
, 8. A client with diabetes mellitus becomes shaky, diaphoretic, and
confused. Which condition should the nurse suspect?
A. Hyperglycemia
B. Hypoglycemia
C. Hypernatremia
D. Diabetic ketoacidosis
Answer: B. Hypoglycemia
Rationale: Shakiness, sweating, confusion, and weakness are common
manifestations of low blood glucose and require prompt treatment.
9. A conscious client with a blood glucose of 52 mg/dL can swallow
safely. What should the nurse provide?
A. Regular insulin
B. 15 g of rapid-acting carbohydrate
C. A high-protein meal only
D. Nothing by mouth
Answer: B. 15 g of rapid-acting carbohydrate
Rationale: A conscious client who can swallow should receive
approximately 15 g of rapid-acting carbohydrate, followed by
reassessment of blood glucose.
10. Which finding is most characteristic of left-sided heart
failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Exam 001 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
1. A nurse is caring for a client who has just returned from surgery.
Which assessment finding requires immediate intervention?
A. Pain rated 6/10
B. Urine output of 35 mL/hr
C. Oxygen saturation of 88%
D. Temperature of 37.4°C (99.3°F)
Answer: C. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and
requires immediate assessment and intervention. Airway and
breathing take priority according to the ABCs.
2. A nurse is preparing to administer oral medications to a client.
Which action is most appropriate?
A. Leave the medications at the bedside
B. Verify the client's identity using two identifiers
C. Ask the roommate to identify the client
D. Administer medications based only on the room number
Answer: B. Verify the client's identity using two identifiers
,Rationale: Using two approved client identifiers helps prevent
medication errors. Room number should never be used as an
identifier.
3. A client with heart failure reports increasing shortness of breath.
Which position should the nurse place the client in?
A. Supine
B. Prone
C. High-Fowler's
D. Trendelenburg
Answer: C. High-Fowler's
Rationale: High-Fowler's positioning promotes lung expansion and
decreases venous return, which can reduce pulmonary congestion and
improve breathing.
4. A nurse is caring for a client receiving a blood transfusion. Which
finding requires immediate action?
A. Temperature of 37°C (98.6°F)
B. Mild thirst
C. Chills and low back pain
D. Heart rate of 78/min
Answer: C. Chills and low back pain
Rationale: Chills and low back pain can indicate an acute hemolytic
transfusion reaction. The nurse should stop the transfusion
immediately and follow the facility's transfusion-reaction protocol.
5. Which intervention is most appropriate for preventing pressure
injuries in an immobile client?
A. Massage reddened areas
B. Reposition the client regularly
,C. Keep the head of bed elevated at all times
D. Use a donut-shaped cushion under the sacrum
Answer: B. Reposition the client regularly
Rationale: Regular repositioning relieves prolonged pressure and
helps prevent tissue injury. Massage of reddened areas can cause
additional tissue damage.
6. A client taking warfarin should be monitored primarily using
which laboratory test?
A. INR
B. aPTT
C. Troponin
D. Hemoglobin A1c
Answer: A. INR
Rationale: The international normalized ratio (INR) is used to monitor
the therapeutic effect of warfarin and guide dosing.
7. A client receiving heparin develops bleeding from the gums.
Which medication should the nurse anticipate administering for
severe heparin-associated bleeding?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Acetylcysteine
Answer: B. Protamine sulfate
Rationale: Protamine sulfate reverses the anticoagulant effects of
unfractionated heparin. Vitamin K is used to reverse warfarin.
, 8. A client with diabetes mellitus becomes shaky, diaphoretic, and
confused. Which condition should the nurse suspect?
A. Hyperglycemia
B. Hypoglycemia
C. Hypernatremia
D. Diabetic ketoacidosis
Answer: B. Hypoglycemia
Rationale: Shakiness, sweating, confusion, and weakness are common
manifestations of low blood glucose and require prompt treatment.
9. A conscious client with a blood glucose of 52 mg/dL can swallow
safely. What should the nurse provide?
A. Regular insulin
B. 15 g of rapid-acting carbohydrate
C. A high-protein meal only
D. Nothing by mouth
Answer: B. 15 g of rapid-acting carbohydrate
Rationale: A conscious client who can swallow should receive
approximately 15 g of rapid-acting carbohydrate, followed by
reassessment of blood glucose.
10. Which finding is most characteristic of left-sided heart
failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
