Florida NCLEX Comprehensive Review Practice Exam I
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1. A nurse is caring for a client with heart failure. Which assessment finding requires
immediate intervention?
A. Bilateral ankle edema
B. Weight gain of 1 lb overnight
C. Crackles throughout both lung fields
D. Fatigue after ambulation
Answer: C. Crackles throughout both lung fields
Rationale: Diffuse crackles indicate pulmonary congestion and possible pulmonary edema,
which can rapidly impair oxygenation. Immediate intervention is necessary to improve
respiratory status. Although edema, fatigue, and slight weight gain are significant findings,
they are not as immediately life-threatening as pulmonary edema.
2. A nurse is preparing to administer regular insulin. Which route is appropriate?
A. Intramuscular
B. Intravenous or subcutaneous
C. Oral
D. Intradermal
Answer: B. Intravenous or subcutaneous
Rationale: Regular insulin is the only insulin that may be administered intravenously in
emergency situations, such as diabetic ketoacidosis. It is also commonly administered
subcutaneously for routine blood glucose management. The other routes are
inappropriate.
, 3. Which electrolyte imbalance places a client at the greatest risk for life-threatening
cardiac dysrhythmias?
A. Mild hyponatremia
B. Hyperkalemia
C. Hypermagnesemia
D. Hypocalcemia
Answer: B. Hyperkalemia
Rationale: Potassium directly affects cardiac conduction. Elevated potassium levels can
produce peaked T waves, widening of the QRS complex, ventricular dysrhythmias, and
cardiac arrest. Prompt recognition and treatment are essential.
4. A postoperative client suddenly develops shortness of breath and chest pain. What
is the nurse's priority action?
A. Encourage coughing and deep breathing.
B. Place the client in Trendelenburg position.
C. Administer oxygen and notify the provider immediately.
D. Offer oral fluids.
Answer: C. Administer oxygen and notify the provider immediately.
Rationale: Sudden chest pain and dyspnea following surgery strongly suggest a pulmonary
embolism. The priority is to support oxygenation, assess vital signs, and notify the
healthcare provider while preparing for emergency interventions.
5. Which laboratory value indicates effective warfarin therapy?
A. INR of 2.5
B. Platelet count of 450,000/mm³
C. WBC count of 7,000/mm³
D. Hemoglobin of 14 g/dL
Answer: A. INR of 2.5
Rationale: The therapeutic INR for most clients receiving warfarin ranges from 2.0 to 3.0.
This value indicates appropriate anticoagulation while minimizing bleeding risk.
, 6. A nurse is teaching a client with hypertension about lifestyle modifications. Which
statement indicates understanding?
A. "I'll stop taking my medication when my blood pressure improves."
B. "I'll limit sodium intake and exercise regularly."
C. "I'll double my medication if my pressure is high."
D. "I'll only check my blood pressure when I feel dizzy."
Answer: B. "I'll limit sodium intake and exercise regularly."
Rationale: Lifestyle modifications, including sodium restriction, exercise, weight
management, smoking cessation, and medication adherence, effectively reduce blood
pressure and cardiovascular risk.
7. Which client should the nurse assess first?
A. A client reporting pain rated 6/10.
B. A client with oxygen saturation of 85%.
C. A client requesting assistance to the bathroom.
D. A client awaiting discharge instructions.
Answer: B. A client with oxygen saturation of 85%.
Rationale: Airway and breathing take priority. An oxygen saturation of 85% indicates
significant hypoxemia requiring immediate assessment and intervention.
8. A nurse is caring for a client receiving morphine. Which assessment finding requires
immediate action?
A. Respiratory rate of 8 breaths/minute
B. Pain rating of 4/10
C. Blood pressure of 138/80 mm Hg
D. Pulse rate of 88 beats/minute
Answer: A. Respiratory rate of 8 breaths/minute
Updated Exam 2026 WITH Recent Newest Verified And Well
Analyzed Exam Questions (Actual Exam 2026-2027) Correct
Detailed & Verified ANSWERS (100% Accurate Solutions)
ALREADY GRADED A+||NEWEST VERSION Of
The Exam Guarantee Pass!!
1. A nurse is caring for a client with heart failure. Which assessment finding requires
immediate intervention?
A. Bilateral ankle edema
B. Weight gain of 1 lb overnight
C. Crackles throughout both lung fields
D. Fatigue after ambulation
Answer: C. Crackles throughout both lung fields
Rationale: Diffuse crackles indicate pulmonary congestion and possible pulmonary edema,
which can rapidly impair oxygenation. Immediate intervention is necessary to improve
respiratory status. Although edema, fatigue, and slight weight gain are significant findings,
they are not as immediately life-threatening as pulmonary edema.
2. A nurse is preparing to administer regular insulin. Which route is appropriate?
A. Intramuscular
B. Intravenous or subcutaneous
C. Oral
D. Intradermal
Answer: B. Intravenous or subcutaneous
Rationale: Regular insulin is the only insulin that may be administered intravenously in
emergency situations, such as diabetic ketoacidosis. It is also commonly administered
subcutaneously for routine blood glucose management. The other routes are
inappropriate.
, 3. Which electrolyte imbalance places a client at the greatest risk for life-threatening
cardiac dysrhythmias?
A. Mild hyponatremia
B. Hyperkalemia
C. Hypermagnesemia
D. Hypocalcemia
Answer: B. Hyperkalemia
Rationale: Potassium directly affects cardiac conduction. Elevated potassium levels can
produce peaked T waves, widening of the QRS complex, ventricular dysrhythmias, and
cardiac arrest. Prompt recognition and treatment are essential.
4. A postoperative client suddenly develops shortness of breath and chest pain. What
is the nurse's priority action?
A. Encourage coughing and deep breathing.
B. Place the client in Trendelenburg position.
C. Administer oxygen and notify the provider immediately.
D. Offer oral fluids.
Answer: C. Administer oxygen and notify the provider immediately.
Rationale: Sudden chest pain and dyspnea following surgery strongly suggest a pulmonary
embolism. The priority is to support oxygenation, assess vital signs, and notify the
healthcare provider while preparing for emergency interventions.
5. Which laboratory value indicates effective warfarin therapy?
A. INR of 2.5
B. Platelet count of 450,000/mm³
C. WBC count of 7,000/mm³
D. Hemoglobin of 14 g/dL
Answer: A. INR of 2.5
Rationale: The therapeutic INR for most clients receiving warfarin ranges from 2.0 to 3.0.
This value indicates appropriate anticoagulation while minimizing bleeding risk.
, 6. A nurse is teaching a client with hypertension about lifestyle modifications. Which
statement indicates understanding?
A. "I'll stop taking my medication when my blood pressure improves."
B. "I'll limit sodium intake and exercise regularly."
C. "I'll double my medication if my pressure is high."
D. "I'll only check my blood pressure when I feel dizzy."
Answer: B. "I'll limit sodium intake and exercise regularly."
Rationale: Lifestyle modifications, including sodium restriction, exercise, weight
management, smoking cessation, and medication adherence, effectively reduce blood
pressure and cardiovascular risk.
7. Which client should the nurse assess first?
A. A client reporting pain rated 6/10.
B. A client with oxygen saturation of 85%.
C. A client requesting assistance to the bathroom.
D. A client awaiting discharge instructions.
Answer: B. A client with oxygen saturation of 85%.
Rationale: Airway and breathing take priority. An oxygen saturation of 85% indicates
significant hypoxemia requiring immediate assessment and intervention.
8. A nurse is caring for a client receiving morphine. Which assessment finding requires
immediate action?
A. Respiratory rate of 8 breaths/minute
B. Pain rating of 4/10
C. Blood pressure of 138/80 mm Hg
D. Pulse rate of 88 beats/minute
Answer: A. Respiratory rate of 8 breaths/minute
