NCLEX RN Adult Medical Surgical
Nursing Exam 1 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A Instant
Download Pdf
Question 1
A client with heart failure is receiving furosemide. Which finding should the
nurse report immediately?
A. Urine output of 1,500 mL/day
B. Potassium level of 2.8 mEq/L
C. Blood pressure of 118/70 mm Hg
D. Mild thirst
Answer: Potassium level of 2.8 mEq/L
Rationale: Furosemide can cause significant potassium loss. Severe
hypokalemia increases the risk for dysrhythmias and requires prompt
intervention.
Question 2
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen.
Which oxygen saturation is generally an appropriate target for a client with
chronic CO₂ retention?
A. 100%
B. 98–100%
C. 88–92%
D. 70–75%
Answer: 88–92%
,Rationale: In many clients with chronic CO₂ retention, controlled oxygen
therapy targeting approximately 88–92% helps improve oxygenation while
reducing the risk of worsening hypercapnia.
Question 3
A client with diabetes mellitus is awake, diaphoretic, and confused. The blood
glucose level is 48 mg/dL. What is the nurse's priority action?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Encourage the client to ambulate
D. Restrict oral fluids
Answer: Give 15 g of rapid-acting carbohydrate
Rationale: A conscious client with symptomatic hypoglycemia should receive
approximately 15 g of fast-acting carbohydrate, followed by reassessment of
glucose.
Question 4
A client with pneumonia has a temperature of 39.2°C (102.6°F), respiratory rate
of 30/min, and oxygen saturation of 86%. Which intervention is the priority?
A. Encourage oral fluids
B. Apply oxygen as prescribed
C. Obtain a sputum culture
D. Administer acetaminophen
Answer: Apply oxygen as prescribed
Rationale: Hypoxemia is the immediate priority. Oxygen supports adequate
tissue oxygenation while other diagnostic and therapeutic interventions are
initiated.
Question 5
A client with a myocardial infarction reports crushing substernal chest pain.
Which medication should the nurse anticipate administering first if prescribed
and not contraindicated?
,A. Nitroglycerin
B. Warfarin
C. Furosemide
D. Digoxin
Answer: Nitroglycerin
Rationale: Nitroglycerin decreases myocardial oxygen demand and can
relieve ischemic chest pain by causing vasodilation.
Question 6
Which assessment finding is most concerning in a client with increased
intracranial pressure?
A. Headache
B. Nausea
C. Decreasing level of consciousness
D. Photophobia
Answer: Decreasing level of consciousness
Rationale: A declining level of consciousness is an early and important
indicator of worsening cerebral dysfunction and increased intracranial
pressure.
Question 7
A client with chronic kidney disease has a potassium level of 6.4 mEq/L. Which
ECG finding should the nurse anticipate?
A. Peaked T waves
B. Prolonged QT interval
C. ST elevation
D. U waves
Answer: Peaked T waves
Rationale: Hyperkalemia commonly causes tall, peaked T waves and may
progress to QRS widening, conduction abnormalities, ventricular
dysrhythmias, and cardiac arrest.
Question 8
, A client is admitted with suspected appendicitis. Which prescription should the
nurse question?
A. Keep the client NPO
B. Administer IV fluids
C. Apply a heating pad to the abdomen
D. Monitor pain
Answer: Apply a heating pad to the abdomen
Rationale: Heat can increase blood flow and may contribute to rupture of an
inflamed appendix. Heat should generally be avoided when appendicitis is
suspected.
Question 9
A client with cirrhosis develops increasing abdominal distention. Which
complication is most likely?
A. Ascites
B. Pneumothorax
C. Hemothorax
D. Pulmonary embolism
Answer: Ascites
Rationale: Portal hypertension and decreased albumin production associated
with cirrhosis contribute to fluid accumulation in the peritoneal cavity,
producing ascites.
Question 10
A client receiving a blood transfusion develops chills, fever, and low back pain.
What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Continue the transfusion and reassess
Answer: Stop the transfusion
Nursing Exam 1 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A Instant
Download Pdf
Question 1
A client with heart failure is receiving furosemide. Which finding should the
nurse report immediately?
A. Urine output of 1,500 mL/day
B. Potassium level of 2.8 mEq/L
C. Blood pressure of 118/70 mm Hg
D. Mild thirst
Answer: Potassium level of 2.8 mEq/L
Rationale: Furosemide can cause significant potassium loss. Severe
hypokalemia increases the risk for dysrhythmias and requires prompt
intervention.
Question 2
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen.
Which oxygen saturation is generally an appropriate target for a client with
chronic CO₂ retention?
A. 100%
B. 98–100%
C. 88–92%
D. 70–75%
Answer: 88–92%
,Rationale: In many clients with chronic CO₂ retention, controlled oxygen
therapy targeting approximately 88–92% helps improve oxygenation while
reducing the risk of worsening hypercapnia.
Question 3
A client with diabetes mellitus is awake, diaphoretic, and confused. The blood
glucose level is 48 mg/dL. What is the nurse's priority action?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Encourage the client to ambulate
D. Restrict oral fluids
Answer: Give 15 g of rapid-acting carbohydrate
Rationale: A conscious client with symptomatic hypoglycemia should receive
approximately 15 g of fast-acting carbohydrate, followed by reassessment of
glucose.
Question 4
A client with pneumonia has a temperature of 39.2°C (102.6°F), respiratory rate
of 30/min, and oxygen saturation of 86%. Which intervention is the priority?
A. Encourage oral fluids
B. Apply oxygen as prescribed
C. Obtain a sputum culture
D. Administer acetaminophen
Answer: Apply oxygen as prescribed
Rationale: Hypoxemia is the immediate priority. Oxygen supports adequate
tissue oxygenation while other diagnostic and therapeutic interventions are
initiated.
Question 5
A client with a myocardial infarction reports crushing substernal chest pain.
Which medication should the nurse anticipate administering first if prescribed
and not contraindicated?
,A. Nitroglycerin
B. Warfarin
C. Furosemide
D. Digoxin
Answer: Nitroglycerin
Rationale: Nitroglycerin decreases myocardial oxygen demand and can
relieve ischemic chest pain by causing vasodilation.
Question 6
Which assessment finding is most concerning in a client with increased
intracranial pressure?
A. Headache
B. Nausea
C. Decreasing level of consciousness
D. Photophobia
Answer: Decreasing level of consciousness
Rationale: A declining level of consciousness is an early and important
indicator of worsening cerebral dysfunction and increased intracranial
pressure.
Question 7
A client with chronic kidney disease has a potassium level of 6.4 mEq/L. Which
ECG finding should the nurse anticipate?
A. Peaked T waves
B. Prolonged QT interval
C. ST elevation
D. U waves
Answer: Peaked T waves
Rationale: Hyperkalemia commonly causes tall, peaked T waves and may
progress to QRS widening, conduction abnormalities, ventricular
dysrhythmias, and cardiac arrest.
Question 8
, A client is admitted with suspected appendicitis. Which prescription should the
nurse question?
A. Keep the client NPO
B. Administer IV fluids
C. Apply a heating pad to the abdomen
D. Monitor pain
Answer: Apply a heating pad to the abdomen
Rationale: Heat can increase blood flow and may contribute to rupture of an
inflamed appendix. Heat should generally be avoided when appendicitis is
suspected.
Question 9
A client with cirrhosis develops increasing abdominal distention. Which
complication is most likely?
A. Ascites
B. Pneumothorax
C. Hemothorax
D. Pulmonary embolism
Answer: Ascites
Rationale: Portal hypertension and decreased albumin production associated
with cirrhosis contribute to fluid accumulation in the peritoneal cavity,
producing ascites.
Question 10
A client receiving a blood transfusion develops chills, fever, and low back pain.
What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Continue the transfusion and reassess
Answer: Stop the transfusion
