NCLEX RN Adult Medical Surgical
Nursing Exam 10 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
Question 1
A nurse is assessing a client with heart failure. Which finding requires
immediate intervention?
A. 2+ bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Pink, frothy sputum
D. Fatigue with activity
Answer: C. Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema,
indicating severe left-sided heart failure and impaired gas exchange.
Immediate oxygenation and emergency treatment are required.
Question 2
A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which prescription should the nurse question?
A. Oxygen at 2 L/min via nasal cannula
B. Encourage pursed-lip breathing
C. Oxygen at 10 L/min via nonrebreather mask continuously
D. Encourage adequate fluid intake if not contraindicated
Answer: C. Oxygen at 10 L/min via nonrebreather mask continuously
,Rationale: Clients with COPD generally require carefully titrated oxygen.
Excessive oxygen administration can worsen hypercapnia in susceptible
clients. Oxygen should be administered at the lowest concentration needed to
maintain the prescribed target saturation.
Question 3
A client with diabetes mellitus is conscious and has a blood glucose level of
52 mg/dL. Which action should the nurse take first?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Administer glucagon intramuscularly
D. Give a high-protein meal
Answer: B. 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 in about 15 minutes.
Question 4
A client with a myocardial infarction reports sudden severe chest pain that is
not relieved by prescribed nitroglycerin. What is the nurse's priority action?
A. Encourage ambulation
B. Notify the healthcare provider or activate the appropriate emergency
response
C. Give the client food
D. Place the client in Trendelenburg position
Answer: B. Notify the healthcare provider or activate the appropriate
emergency response
Rationale: Persistent or worsening chest pain after nitroglycerin may indicate
ongoing myocardial ischemia or infarction. Rapid evaluation and intervention
are essential.
,Question 5
A client receiving warfarin has an INR of 5.8. Which action should the nurse
anticipate?
A. Increase the warfarin dose
B. Administer the next dose as scheduled
C. Hold warfarin and notify the healthcare provider
D. Administer aspirin
Answer: C. Hold warfarin and notify the healthcare provider
Rationale: An INR of 5.8 represents excessive anticoagulation and an
increased bleeding risk. Warfarin is typically withheld and further
management is determined according to the INR and presence or absence of
bleeding.
Question 6
A client with chronic kidney disease has a serum potassium level of 6.7
mEq/L. Which finding is most concerning?
A. Muscle weakness
B. Peaked T waves on the ECG
C. Fatigue
D. Nausea
Answer: B. Peaked T waves on the ECG
Rationale: Severe hyperkalemia can cause life-threatening cardiac
dysrhythmias. Peaked T waves are an important ECG manifestation requiring
immediate intervention.
Question 7
A client is admitted with suspected bacterial meningitis. Which intervention
is the priority?
, A. Place the client on droplet precautions
B. Encourage bright lighting
C. Restrict all fluids
D. Place the client in a high-Fowler position permanently
Answer: A. Place the client on droplet precautions
Rationale: Suspected bacterial meningitis requires immediate droplet
precautions to reduce transmission of respiratory pathogens.
Question 8
A client with a gastrointestinal hemorrhage has a blood pressure of 84/50
mmHg and a heart rate of 128/min. What should the nurse do first?
A. Give an oral antacid
B. Establish or maintain large-bore IV access
C. Encourage the client to walk
D. Administer a laxative
Answer: B. Establish or maintain large-bore IV access
Rationale: Hypotension and tachycardia suggest hypovolemic shock from
blood loss. Rapid IV access is essential for fluid and blood-product
resuscitation.
Question 9
A client with Addison disease is experiencing vomiting, severe weakness,
hypotension, and confusion. Which complication should the nurse suspect?
A. Thyroid storm
B. Addisonian crisis
C. Cushing syndrome
D. Diabetes insipidus
Answer: B. Addisonian crisis
Nursing Exam 10 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
Question 1
A nurse is assessing a client with heart failure. Which finding requires
immediate intervention?
A. 2+ bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Pink, frothy sputum
D. Fatigue with activity
Answer: C. Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema,
indicating severe left-sided heart failure and impaired gas exchange.
Immediate oxygenation and emergency treatment are required.
Question 2
A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which prescription should the nurse question?
A. Oxygen at 2 L/min via nasal cannula
B. Encourage pursed-lip breathing
C. Oxygen at 10 L/min via nonrebreather mask continuously
D. Encourage adequate fluid intake if not contraindicated
Answer: C. Oxygen at 10 L/min via nonrebreather mask continuously
,Rationale: Clients with COPD generally require carefully titrated oxygen.
Excessive oxygen administration can worsen hypercapnia in susceptible
clients. Oxygen should be administered at the lowest concentration needed to
maintain the prescribed target saturation.
Question 3
A client with diabetes mellitus is conscious and has a blood glucose level of
52 mg/dL. Which action should the nurse take first?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Administer glucagon intramuscularly
D. Give a high-protein meal
Answer: B. 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 in about 15 minutes.
Question 4
A client with a myocardial infarction reports sudden severe chest pain that is
not relieved by prescribed nitroglycerin. What is the nurse's priority action?
A. Encourage ambulation
B. Notify the healthcare provider or activate the appropriate emergency
response
C. Give the client food
D. Place the client in Trendelenburg position
Answer: B. Notify the healthcare provider or activate the appropriate
emergency response
Rationale: Persistent or worsening chest pain after nitroglycerin may indicate
ongoing myocardial ischemia or infarction. Rapid evaluation and intervention
are essential.
,Question 5
A client receiving warfarin has an INR of 5.8. Which action should the nurse
anticipate?
A. Increase the warfarin dose
B. Administer the next dose as scheduled
C. Hold warfarin and notify the healthcare provider
D. Administer aspirin
Answer: C. Hold warfarin and notify the healthcare provider
Rationale: An INR of 5.8 represents excessive anticoagulation and an
increased bleeding risk. Warfarin is typically withheld and further
management is determined according to the INR and presence or absence of
bleeding.
Question 6
A client with chronic kidney disease has a serum potassium level of 6.7
mEq/L. Which finding is most concerning?
A. Muscle weakness
B. Peaked T waves on the ECG
C. Fatigue
D. Nausea
Answer: B. Peaked T waves on the ECG
Rationale: Severe hyperkalemia can cause life-threatening cardiac
dysrhythmias. Peaked T waves are an important ECG manifestation requiring
immediate intervention.
Question 7
A client is admitted with suspected bacterial meningitis. Which intervention
is the priority?
, A. Place the client on droplet precautions
B. Encourage bright lighting
C. Restrict all fluids
D. Place the client in a high-Fowler position permanently
Answer: A. Place the client on droplet precautions
Rationale: Suspected bacterial meningitis requires immediate droplet
precautions to reduce transmission of respiratory pathogens.
Question 8
A client with a gastrointestinal hemorrhage has a blood pressure of 84/50
mmHg and a heart rate of 128/min. What should the nurse do first?
A. Give an oral antacid
B. Establish or maintain large-bore IV access
C. Encourage the client to walk
D. Administer a laxative
Answer: B. Establish or maintain large-bore IV access
Rationale: Hypotension and tachycardia suggest hypovolemic shock from
blood loss. Rapid IV access is essential for fluid and blood-product
resuscitation.
Question 9
A client with Addison disease is experiencing vomiting, severe weakness,
hypotension, and confusion. Which complication should the nurse suspect?
A. Thyroid storm
B. Addisonian crisis
C. Cushing syndrome
D. Diabetes insipidus
Answer: B. Addisonian crisis
