NCLEX-RN Comprehensive Practice Exam
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A|
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1. A nurse is assessing a client who has developed a sudden change
in level of consciousness. Which finding requires the nurse's
immediate attention?
a. Mild headache
b. New confusion and difficulty arousing
c. Decreased appetite
d. Fatigue after activity
Answer: b. New confusion and difficulty arousing
Rationale: A sudden alteration in level of consciousness can indicate
acute neurological deterioration, hypoxia, hypoglycemia, stroke, or
another life-threatening condition. The nurse should immediately
,assess airway, breathing, circulation, oxygenation, and neurological
status.
2. A client with heart failure reports increasing shortness of breath
and difficulty breathing when lying flat. Which intervention should
the nurse implement first?
a. Encourage oral fluids
b. Place the client in a high-Fowler position
c. Assist the client to ambulate
d. Place the client in a supine position
Answer: b. Place the client in a high-Fowler position
Rationale: High-Fowler positioning promotes maximum lung
expansion and decreases venous return to the heart, which can
improve breathing in a client experiencing pulmonary congestion.
Other interventions may be necessary, but positioning is an
immediate nursing action.
3. The nurse is caring for a client receiving intravenous potassium
chloride. Which action is most important?
a. Administer potassium by rapid IV push
b. Monitor the client's urine output
,c. Restrict all oral fluids
d. Place the client on bed rest
Answer: b. Monitor the client's urine output
Rationale: Potassium is primarily excreted by the kidneys. Adequate
renal function and urine output are essential before administering
potassium because impaired excretion can cause dangerous
hyperkalemia and cardiac dysrhythmias. Potassium must never be
administered by IV push.
4. A client with diabetes mellitus is experiencing diaphoresis,
tremors, and confusion. Which condition should the nurse
suspect?
a. Hyperglycemia
b. Hypoglycemia
c. Hypernatremia
d. Diabetic ketoacidosis
Answer: b. Hypoglycemia
Rationale: Sweating, tremors, confusion, weakness, and tachycardia
are classic manifestations of hypoglycemia. The nurse should check
the blood glucose promptly and provide an appropriate rapid-acting
carbohydrate if the client is conscious and able to swallow.
, 5. Which assessment finding is most concerning in a client receiving
opioid analgesics?
a. Respiratory rate of 8/min
b. Mild nausea
c. Constipation
d. Drowsiness after administration
Answer: a. Respiratory rate of 8/min
Rationale: Opioids can cause respiratory depression. A respiratory
rate of 8/min is significantly decreased and may indicate opioid
toxicity. The nurse should immediately assess the client's airway and
breathing and follow the appropriate protocol for opioid reversal,
including naloxone when indicated.
6. A nurse is preparing to administer digoxin. Which finding should
cause the nurse to withhold the medication and notify the
provider?
a. Apical pulse of 54/min
b. Blood pressure of 128/76 mmHg
c. Respiratory rate of 18/min
d. Temperature of 37°C (98.6°F)
Answer: a. Apical pulse of 54/min
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A|
Instant Download Pdf
1. A nurse is assessing a client who has developed a sudden change
in level of consciousness. Which finding requires the nurse's
immediate attention?
a. Mild headache
b. New confusion and difficulty arousing
c. Decreased appetite
d. Fatigue after activity
Answer: b. New confusion and difficulty arousing
Rationale: A sudden alteration in level of consciousness can indicate
acute neurological deterioration, hypoxia, hypoglycemia, stroke, or
another life-threatening condition. The nurse should immediately
,assess airway, breathing, circulation, oxygenation, and neurological
status.
2. A client with heart failure reports increasing shortness of breath
and difficulty breathing when lying flat. Which intervention should
the nurse implement first?
a. Encourage oral fluids
b. Place the client in a high-Fowler position
c. Assist the client to ambulate
d. Place the client in a supine position
Answer: b. Place the client in a high-Fowler position
Rationale: High-Fowler positioning promotes maximum lung
expansion and decreases venous return to the heart, which can
improve breathing in a client experiencing pulmonary congestion.
Other interventions may be necessary, but positioning is an
immediate nursing action.
3. The nurse is caring for a client receiving intravenous potassium
chloride. Which action is most important?
a. Administer potassium by rapid IV push
b. Monitor the client's urine output
,c. Restrict all oral fluids
d. Place the client on bed rest
Answer: b. Monitor the client's urine output
Rationale: Potassium is primarily excreted by the kidneys. Adequate
renal function and urine output are essential before administering
potassium because impaired excretion can cause dangerous
hyperkalemia and cardiac dysrhythmias. Potassium must never be
administered by IV push.
4. A client with diabetes mellitus is experiencing diaphoresis,
tremors, and confusion. Which condition should the nurse
suspect?
a. Hyperglycemia
b. Hypoglycemia
c. Hypernatremia
d. Diabetic ketoacidosis
Answer: b. Hypoglycemia
Rationale: Sweating, tremors, confusion, weakness, and tachycardia
are classic manifestations of hypoglycemia. The nurse should check
the blood glucose promptly and provide an appropriate rapid-acting
carbohydrate if the client is conscious and able to swallow.
, 5. Which assessment finding is most concerning in a client receiving
opioid analgesics?
a. Respiratory rate of 8/min
b. Mild nausea
c. Constipation
d. Drowsiness after administration
Answer: a. Respiratory rate of 8/min
Rationale: Opioids can cause respiratory depression. A respiratory
rate of 8/min is significantly decreased and may indicate opioid
toxicity. The nurse should immediately assess the client's airway and
breathing and follow the appropriate protocol for opioid reversal,
including naloxone when indicated.
6. A nurse is preparing to administer digoxin. Which finding should
cause the nurse to withhold the medication and notify the
provider?
a. Apical pulse of 54/min
b. Blood pressure of 128/76 mmHg
c. Respiratory rate of 18/min
d. Temperature of 37°C (98.6°F)
Answer: a. Apical pulse of 54/min
