NCLEX-RN 2026/2027 100 QUESTIONS AND
ANSWERS
Exam
1.A client with congestive heart failure reports shortness of breath
and edema. Which assessment finding is the highest priority?
A. Mild ankle swelling
B. Shortness of breath at rest
C. Weight gain of 1 lb
D. Slight fatigue
**Answer: B**
**Rationale:** Shortness of breath at rest indicates worsening
pulmonary congestion and potential respiratory compromise, which
is life-threatening and requires immediate attention. This represents
a priority airway/breathing concern over other symptoms .
---
## Question 2
A client with type 1 diabetes reports feeling shaky, sweaty, and dizzy.
Blood glucose is 48 mg/dL. What is the priority action?
,A. Recheck blood sugar in 30 minutes
B. Administer 15 g of fast-acting carbohydrate
C. Provide a protein-rich snack
D. Notify the provider immediately
**Answer: B**
**Rationale:** Hypoglycemia is an immediate threat. Fast-acting
carbohydrates (such as 4 oz of fruit juice, 3-4 glucose tablets, or 6-10
hard candies) quickly raise blood glucose, preventing further
deterioration. The rule for hypoglycemia is to treat first, then recheck
.
---
## Question 3
A client with pneumonia has O₂ saturation of 88%. What is the most
appropriate nursing action?
A. Encourage ambulation
B. Administer prescribed supplemental oxygen
C. Increase oral fluid intake
D. Reassess in 2 hours
**Answer: B**
,**Rationale:** Oxygen saturation below 90% indicates hypoxemia;
supplemental oxygen is necessary to prevent tissue hypoxia. This is
an immediate intervention priority .
---
## Question 4
A postoperative client reports sudden calf pain and swelling. What is
the priority intervention?
A. Apply heat to the leg
B. Elevate the leg and continue ambulation
C. Notify the provider immediately
D. Massage the calf
**Answer: C**
**Rationale:** These are classic signs of deep vein thrombosis (DVT).
Immediate notification is critical to prevent a potentially fatal
pulmonary embolism. Never massage or apply heat to a suspected
DVT .
---
, ## Question 5
A client with asthma is experiencing an acute exacerbation. Which
medication should the nurse administer first?
A. Albuterol via nebulizer
B. Montelukast orally
C. Fluticasone inhaler
D. Prednisone orally
**Answer: A**
**Rationale:** Albuterol is a short-acting bronchodilator for
immediate relief during acute exacerbations. It works quickly to open
airways .
---
## Question 6
A client with a new tracheostomy shows increased work of breathing
and audible stridor. What is the priority action?
A. Suction the tracheostomy
B. Assess airway and prepare for potential intubation
C. Encourage deep breathing exercises
D. Apply warm compresses
ANSWERS
Exam
1.A client with congestive heart failure reports shortness of breath
and edema. Which assessment finding is the highest priority?
A. Mild ankle swelling
B. Shortness of breath at rest
C. Weight gain of 1 lb
D. Slight fatigue
**Answer: B**
**Rationale:** Shortness of breath at rest indicates worsening
pulmonary congestion and potential respiratory compromise, which
is life-threatening and requires immediate attention. This represents
a priority airway/breathing concern over other symptoms .
---
## Question 2
A client with type 1 diabetes reports feeling shaky, sweaty, and dizzy.
Blood glucose is 48 mg/dL. What is the priority action?
,A. Recheck blood sugar in 30 minutes
B. Administer 15 g of fast-acting carbohydrate
C. Provide a protein-rich snack
D. Notify the provider immediately
**Answer: B**
**Rationale:** Hypoglycemia is an immediate threat. Fast-acting
carbohydrates (such as 4 oz of fruit juice, 3-4 glucose tablets, or 6-10
hard candies) quickly raise blood glucose, preventing further
deterioration. The rule for hypoglycemia is to treat first, then recheck
.
---
## Question 3
A client with pneumonia has O₂ saturation of 88%. What is the most
appropriate nursing action?
A. Encourage ambulation
B. Administer prescribed supplemental oxygen
C. Increase oral fluid intake
D. Reassess in 2 hours
**Answer: B**
,**Rationale:** Oxygen saturation below 90% indicates hypoxemia;
supplemental oxygen is necessary to prevent tissue hypoxia. This is
an immediate intervention priority .
---
## Question 4
A postoperative client reports sudden calf pain and swelling. What is
the priority intervention?
A. Apply heat to the leg
B. Elevate the leg and continue ambulation
C. Notify the provider immediately
D. Massage the calf
**Answer: C**
**Rationale:** These are classic signs of deep vein thrombosis (DVT).
Immediate notification is critical to prevent a potentially fatal
pulmonary embolism. Never massage or apply heat to a suspected
DVT .
---
, ## Question 5
A client with asthma is experiencing an acute exacerbation. Which
medication should the nurse administer first?
A. Albuterol via nebulizer
B. Montelukast orally
C. Fluticasone inhaler
D. Prednisone orally
**Answer: A**
**Rationale:** Albuterol is a short-acting bronchodilator for
immediate relief during acute exacerbations. It works quickly to open
airways .
---
## Question 6
A client with a new tracheostomy shows increased work of breathing
and audible stridor. What is the priority action?
A. Suction the tracheostomy
B. Assess airway and prepare for potential intubation
C. Encourage deep breathing exercises
D. Apply warm compresses
