NCLEX-RN LEVEL III EXAM QUESTIONS
AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A |
INSTANT DOWNLOAD
1. A nurse is assessing a patient with congestive heart failure. Which
of the following is an early sign of fluid overload?
A. Peripheral edema
B. Weight loss
C. Crackles in the lungs
D. Increased urine output
Answer: C
Rationale: Crackles in the lungs are an early indicator of pulmonary
congestion due to fluid overload. Peripheral edema occurs later.
2. The nurse is caring for a client on digoxin therapy. Which of the
following should be monitored closely?
A. Respiratory rate
B. Heart rate
C. Blood pressure
D. Serum potassium
Answer: B
Rationale: Digoxin can cause bradycardia. Monitoring heart rate is
critical to avoid toxicity.
,3. A patient receiving morphine reports shortness of breath and
respiratory depression. What is the nurse's priority action?
A. Administer naloxone
B. Encourage deep breathing
C. Place in a high Fowler’s position
D. Call the healthcare provider
Answer: A
Rationale: Naloxone is the antidote for opioid overdose and should be
administered immediately to reverse respiratory depression.
4. Which intervention is appropriate for a patient with a nasogastric
tube on continuous suctioning?
A. Irrigate with 30 mL of water every 4 hours
B. Clamp the tube for 1 hour after feeding
C. Monitor electrolytes closely
D. Encourage the patient to eat solid foods
Answer: C
Rationale: Continuous suctioning can cause electrolyte imbalances,
especially loss of potassium and sodium, which must be monitored.
5. A client with diabetes mellitus reports burning on urination. Which
diagnostic test is most appropriate initially?
A. Serum glucose
B. Urinalysis
C. Renal ultrasound
D. Hemoglobin A1C
Answer: B
Rationale: Urinalysis is the first-line test to detect urinary tract
infections, common in diabetics.
,6. Which of the following is a sign of hypoglycemia in a patient
receiving insulin?
A. Polyuria
B. Tachycardia
C. Weight gain
D. Fruity breath odor
Answer: B
Rationale: Hypoglycemia often presents with sympathetic activation,
including tachycardia, tremors, and diaphoresis.
7. A nurse teaches a client about subcutaneous heparin injections.
Which statement indicates understanding?
A. “I should massage the site after injection.”
B. “I will inject into the abdomen and rotate sites.”
C. “I should aspirate before injecting.”
D. “I should apply ice to the injection site.”
Answer: B
Rationale: Heparin should be injected subcutaneously into the abdomen
and sites rotated to prevent bruising.
8. A patient with COPD is receiving oxygen at 2 L/min via nasal
cannula. Which assessment finding requires immediate intervention?
A. Oxygen saturation of 92%
B. Confusion and somnolence
C. Mild shortness of breath
D. Use of accessory muscles
Answer: B
, Rationale: Confusion and somnolence indicate CO₂ retention and
possible hypoventilation, requiring immediate action.
9. The nurse is caring for a client post-mastectomy. Which action
helps prevent lymphedema?
A. Avoiding blood pressure measurement in the affected arm
B. Elevating the affected arm only at night
C. Encouraging heavy lifting
D. Applying constrictive bandages
Answer: A
Rationale: Avoiding venipuncture or blood pressure measurement in the
affected arm reduces risk of lymphedema.
10. A patient has a new prescription for metoprolol. Which is the
priority assessment before administration?
A. Blood pressure and heart rate
B. Respiratory rate
C. Blood glucose
D. Weight
Answer: A
Rationale: Metoprolol is a beta-blocker that can cause bradycardia and
hypotension. Heart rate and BP must be checked prior to
administration.
11. Which of the following findings indicates a client is experiencing
hypovolemic shock?
A. Warm, flushed skin
B. Hypotension and tachycardia
AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A |
INSTANT DOWNLOAD
1. A nurse is assessing a patient with congestive heart failure. Which
of the following is an early sign of fluid overload?
A. Peripheral edema
B. Weight loss
C. Crackles in the lungs
D. Increased urine output
Answer: C
Rationale: Crackles in the lungs are an early indicator of pulmonary
congestion due to fluid overload. Peripheral edema occurs later.
2. The nurse is caring for a client on digoxin therapy. Which of the
following should be monitored closely?
A. Respiratory rate
B. Heart rate
C. Blood pressure
D. Serum potassium
Answer: B
Rationale: Digoxin can cause bradycardia. Monitoring heart rate is
critical to avoid toxicity.
,3. A patient receiving morphine reports shortness of breath and
respiratory depression. What is the nurse's priority action?
A. Administer naloxone
B. Encourage deep breathing
C. Place in a high Fowler’s position
D. Call the healthcare provider
Answer: A
Rationale: Naloxone is the antidote for opioid overdose and should be
administered immediately to reverse respiratory depression.
4. Which intervention is appropriate for a patient with a nasogastric
tube on continuous suctioning?
A. Irrigate with 30 mL of water every 4 hours
B. Clamp the tube for 1 hour after feeding
C. Monitor electrolytes closely
D. Encourage the patient to eat solid foods
Answer: C
Rationale: Continuous suctioning can cause electrolyte imbalances,
especially loss of potassium and sodium, which must be monitored.
5. A client with diabetes mellitus reports burning on urination. Which
diagnostic test is most appropriate initially?
A. Serum glucose
B. Urinalysis
C. Renal ultrasound
D. Hemoglobin A1C
Answer: B
Rationale: Urinalysis is the first-line test to detect urinary tract
infections, common in diabetics.
,6. Which of the following is a sign of hypoglycemia in a patient
receiving insulin?
A. Polyuria
B. Tachycardia
C. Weight gain
D. Fruity breath odor
Answer: B
Rationale: Hypoglycemia often presents with sympathetic activation,
including tachycardia, tremors, and diaphoresis.
7. A nurse teaches a client about subcutaneous heparin injections.
Which statement indicates understanding?
A. “I should massage the site after injection.”
B. “I will inject into the abdomen and rotate sites.”
C. “I should aspirate before injecting.”
D. “I should apply ice to the injection site.”
Answer: B
Rationale: Heparin should be injected subcutaneously into the abdomen
and sites rotated to prevent bruising.
8. A patient with COPD is receiving oxygen at 2 L/min via nasal
cannula. Which assessment finding requires immediate intervention?
A. Oxygen saturation of 92%
B. Confusion and somnolence
C. Mild shortness of breath
D. Use of accessory muscles
Answer: B
, Rationale: Confusion and somnolence indicate CO₂ retention and
possible hypoventilation, requiring immediate action.
9. The nurse is caring for a client post-mastectomy. Which action
helps prevent lymphedema?
A. Avoiding blood pressure measurement in the affected arm
B. Elevating the affected arm only at night
C. Encouraging heavy lifting
D. Applying constrictive bandages
Answer: A
Rationale: Avoiding venipuncture or blood pressure measurement in the
affected arm reduces risk of lymphedema.
10. A patient has a new prescription for metoprolol. Which is the
priority assessment before administration?
A. Blood pressure and heart rate
B. Respiratory rate
C. Blood glucose
D. Weight
Answer: A
Rationale: Metoprolol is a beta-blocker that can cause bradycardia and
hypotension. Heart rate and BP must be checked prior to
administration.
11. Which of the following findings indicates a client is experiencing
hypovolemic shock?
A. Warm, flushed skin
B. Hypotension and tachycardia
