NCLEX-RN Comprehensive Practice
Exam 001 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
Instructions: Choose the best answer for each question. Correct answers are
bolded. Rationales are bold italicized. All major NCLEX-RN client-needs
categories are represented.
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 (2.2 lb) in 24 hours
C. Crackles at the lung bases
D. Severe dyspnea with pink, frothy sputum
Answer: Severe dyspnea with pink, frothy sputum
Rationale: Pink, frothy sputum with severe dyspnea indicates acute
pulmonary edema, a life-threatening complication of heart failure. The nurse
should prioritize airway and breathing and initiate emergency interventions.
2. A client receiving IV potassium chloride reports burning at the IV site. What
should the nurse do first?
A. Slow the infusion
B. Apply a warm compress
C. Assess the IV site for infiltration
D. Notify the health care provider
Answer: Assess the IV site for infiltration
,Rationale: Burning during IV potassium administration may indicate
infiltration or phlebitis. The nurse should assess the IV site immediately
before determining further intervention.
3. A client with diabetes mellitus has a blood glucose level of 52 mg/dL (2.9
mmol/L) and is awake and able to swallow. Which action is appropriate?
A. Administer regular insulin
B. Give 15 g of a rapid-acting carbohydrate
C. Give glucagon intramuscularly
D. Restrict oral fluids
Answer: Give 15 g of a rapid-acting carbohydrate
Rationale: A conscious client who can safely swallow should receive
approximately 15 g of rapid-acting carbohydrate, followed by reassessment
of blood glucose after about 15 minutes.
4. A nurse is caring for a client taking warfarin. Which laboratory value is
most important to monitor?
A. aPTT
B. Platelet count
C. INR
D. Serum sodium
Answer: INR
Rationale: The international normalized ratio (INR) is used to monitor the
therapeutic effect of warfarin and assess bleeding risk.
5. A client with chronic obstructive pulmonary disease is receiving oxygen.
Which prescription should the nurse question?
A. Oxygen at 1–2 L/min via nasal cannula
B. Encourage pursed-lip breathing
C. Maintain oxygen saturation at the prescribed target
D. Administer oxygen at 15 L/min via nonrebreather mask continuously without
reassessment
,Answer: Administer oxygen at 15 L/min via nonrebreather mask continuously
without reassessment
Rationale: Excessive oxygen administration can worsen ventilation-perfusion
imbalance in some clients with severe COPD. Oxygen should be carefully
titrated to the prescribed target and the client's clinical condition.
6. 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. Obtain another blood sample before stopping the transfusion
Answer: Stop the transfusion
Rationale: These findings may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the IV line
should generally be maintained with normal saline using appropriate tubing.
7. A nurse is teaching a client who is prescribed lisinopril. Which statement
indicates understanding?
A. "I should stop the medication if I develop a mild cough."
B. "I should report swelling of my lips or tongue immediately."
C. "This medication will increase my potassium loss."
D. "I should take potassium supplements routinely."
Answer: "I should report swelling of my lips or tongue immediately."
Rationale: Facial, lip, or tongue swelling may indicate angioedema, a
potentially life-threatening adverse effect of ACE inhibitors requiring
immediate evaluation.
8. A postoperative client suddenly develops dyspnea, chest pain, and
tachycardia. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
, C. Pneumonia
D. Fluid overload
Answer: Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia
are classic findings associated with pulmonary embolism.
9. A client with suspected bacterial meningitis is admitted. Which infection-
control precaution is appropriate initially?
A. Airborne precautions
B. Contact precautions only
C. Droplet precautions
D. Protective isolation
Answer: Droplet precautions
Rationale: Suspected meningococcal meningitis requires droplet precautions
because the organism can be transmitted through respiratory droplets.
10. Which assessment finding is most concerning in a client with increased
intracranial pressure?
A. Headache
B. Nausea
C. Decreased level of consciousness
D. Photophobia
Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening neurologic function and increased intracranial pressure.
11. A client with SIADH has a serum sodium level of 118 mEq/L (118 mmol/L).
Which intervention is the priority?
A. Encourage free-water intake
B. Institute seizure precautions
C. Administer hypotonic IV fluids
D. Encourage a low-sodium diet
Answer: Institute seizure precautions
Exam 001 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
Instructions: Choose the best answer for each question. Correct answers are
bolded. Rationales are bold italicized. All major NCLEX-RN client-needs
categories are represented.
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 (2.2 lb) in 24 hours
C. Crackles at the lung bases
D. Severe dyspnea with pink, frothy sputum
Answer: Severe dyspnea with pink, frothy sputum
Rationale: Pink, frothy sputum with severe dyspnea indicates acute
pulmonary edema, a life-threatening complication of heart failure. The nurse
should prioritize airway and breathing and initiate emergency interventions.
2. A client receiving IV potassium chloride reports burning at the IV site. What
should the nurse do first?
A. Slow the infusion
B. Apply a warm compress
C. Assess the IV site for infiltration
D. Notify the health care provider
Answer: Assess the IV site for infiltration
,Rationale: Burning during IV potassium administration may indicate
infiltration or phlebitis. The nurse should assess the IV site immediately
before determining further intervention.
3. A client with diabetes mellitus has a blood glucose level of 52 mg/dL (2.9
mmol/L) and is awake and able to swallow. Which action is appropriate?
A. Administer regular insulin
B. Give 15 g of a rapid-acting carbohydrate
C. Give glucagon intramuscularly
D. Restrict oral fluids
Answer: Give 15 g of a rapid-acting carbohydrate
Rationale: A conscious client who can safely swallow should receive
approximately 15 g of rapid-acting carbohydrate, followed by reassessment
of blood glucose after about 15 minutes.
4. A nurse is caring for a client taking warfarin. Which laboratory value is
most important to monitor?
A. aPTT
B. Platelet count
C. INR
D. Serum sodium
Answer: INR
Rationale: The international normalized ratio (INR) is used to monitor the
therapeutic effect of warfarin and assess bleeding risk.
5. A client with chronic obstructive pulmonary disease is receiving oxygen.
Which prescription should the nurse question?
A. Oxygen at 1–2 L/min via nasal cannula
B. Encourage pursed-lip breathing
C. Maintain oxygen saturation at the prescribed target
D. Administer oxygen at 15 L/min via nonrebreather mask continuously without
reassessment
,Answer: Administer oxygen at 15 L/min via nonrebreather mask continuously
without reassessment
Rationale: Excessive oxygen administration can worsen ventilation-perfusion
imbalance in some clients with severe COPD. Oxygen should be carefully
titrated to the prescribed target and the client's clinical condition.
6. 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. Obtain another blood sample before stopping the transfusion
Answer: Stop the transfusion
Rationale: These findings may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the IV line
should generally be maintained with normal saline using appropriate tubing.
7. A nurse is teaching a client who is prescribed lisinopril. Which statement
indicates understanding?
A. "I should stop the medication if I develop a mild cough."
B. "I should report swelling of my lips or tongue immediately."
C. "This medication will increase my potassium loss."
D. "I should take potassium supplements routinely."
Answer: "I should report swelling of my lips or tongue immediately."
Rationale: Facial, lip, or tongue swelling may indicate angioedema, a
potentially life-threatening adverse effect of ACE inhibitors requiring
immediate evaluation.
8. A postoperative client suddenly develops dyspnea, chest pain, and
tachycardia. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
, C. Pneumonia
D. Fluid overload
Answer: Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia
are classic findings associated with pulmonary embolism.
9. A client with suspected bacterial meningitis is admitted. Which infection-
control precaution is appropriate initially?
A. Airborne precautions
B. Contact precautions only
C. Droplet precautions
D. Protective isolation
Answer: Droplet precautions
Rationale: Suspected meningococcal meningitis requires droplet precautions
because the organism can be transmitted through respiratory droplets.
10. Which assessment finding is most concerning in a client with increased
intracranial pressure?
A. Headache
B. Nausea
C. Decreased level of consciousness
D. Photophobia
Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening neurologic function and increased intracranial pressure.
11. A client with SIADH has a serum sodium level of 118 mEq/L (118 mmol/L).
Which intervention is the priority?
A. Encourage free-water intake
B. Institute seizure precautions
C. Administer hypotonic IV fluids
D. Encourage a low-sodium diet
Answer: Institute seizure precautions
