Florida NCLEX Comprehensive Review Practice Exam IV
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1. A nurse is caring for a client with heart failure who reports increasing shortness of
breath when lying flat. Which intervention should the nurse implement first?
A. Administer a prescribed diuretic.
B. Place the client in High Fowler's position.
C. Restrict oral fluids.
D. Obtain a daily weight.
Answer: B. Place the client in High Fowler's position.
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, improving
oxygenation is the immediate concern. High Fowler's position decreases venous return to
the heart and promotes lung expansion, reducing dyspnea. Medication administration, fluid
restriction, and daily weights are appropriate but are secondary after improving breathing.
2. A client receiving heparin therapy suddenly develops bleeding from the gums.
Which medication should the nurse anticipate administering?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Acetylcysteine
Answer: B. Protamine sulfate
Rationale: Protamine sulfate is the antidote for heparin toxicity. Vitamin K reverses warfarin
effects. Naloxone reverses opioid overdose, while acetylcysteine treats acetaminophen
toxicity.
, 3. Which laboratory value should the nurse report immediately for a client receiving
chemotherapy?
A. Hemoglobin 12 g/dL
B. Platelet count 240,000/mm³
C. White blood cell count 1,200/mm³
D. Sodium 138 mEq/L
Answer: C. White blood cell count 1,200/mm³
Rationale: A WBC count of 1,200/mm³ indicates severe leukopenia and greatly increases
infection risk. Prompt intervention, protective precautions, and provider notification are
essential.
4. A nurse teaches a client with type 1 diabetes about hypoglycemia. Which symptom
should the client recognize first?
A. Fruity breath odor
B. Increased thirst
C. Shakiness and sweating
D. Deep respirations
Answer: C. Shakiness and sweating
Rationale: Early hypoglycemia activates the sympathetic nervous system, producing
tremors, diaphoresis, tachycardia, and hunger. Fruity breath, excessive thirst, and
Kussmaul respirations are associated with hyperglycemia.
5. Which finding indicates effective pain management after administering IV
morphine?
A. Respiratory rate decreases from 18 to 16 breaths/min.
B. Pain decreases from 8/10 to 3/10.
C. Blood pressure increases slightly.
D. Oxygen saturation decreases to 90%.
Answer: B. Pain decreases from 8/10 to 3/10.
Rationale: Pain relief is best evaluated using the client's self-report. A reduction to 3/10
demonstrates effective analgesia. Oxygen desaturation is an adverse effect requiring
intervention.
, 6. A nurse is caring for a postoperative client. Which assessment finding requires
immediate action?
A. Temperature 99.4°F (37.4°C)
B. Blood pressure 118/74 mm Hg
C. Absent bowel sounds immediately after surgery
D. Oxygen saturation 88% on room air
Answer: D. Oxygen saturation 88% on room air.
Rationale: Hypoxemia is an immediate threat to tissue oxygenation and requires prompt
intervention such as oxygen administration and further assessment. Mild postoperative
ileus is expected initially.
7. Which client is at greatest risk for developing deep vein thrombosis?
A. A client walking after surgery
B. A client on prolonged bed rest after hip surgery
C. A client receiving antibiotics
D. A client with seasonal allergies
Answer: B. A client on prolonged bed rest after hip surgery.
Rationale: Orthopedic surgery and immobility significantly increase venous stasis and clot
formation risk.
8. Which electrolyte imbalance is most likely in a client experiencing prolonged
vomiting?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypermagnesemia
Answer: B. Hypokalemia.
Rationale: Vomiting causes potassium loss and metabolic alkalosis, resulting in
hypokalemia.
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 who reports increasing shortness of
breath when lying flat. Which intervention should the nurse implement first?
A. Administer a prescribed diuretic.
B. Place the client in High Fowler's position.
C. Restrict oral fluids.
D. Obtain a daily weight.
Answer: B. Place the client in High Fowler's position.
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, improving
oxygenation is the immediate concern. High Fowler's position decreases venous return to
the heart and promotes lung expansion, reducing dyspnea. Medication administration, fluid
restriction, and daily weights are appropriate but are secondary after improving breathing.
2. A client receiving heparin therapy suddenly develops bleeding from the gums.
Which medication should the nurse anticipate administering?
A. Vitamin K
B. Protamine sulfate
C. Naloxone
D. Acetylcysteine
Answer: B. Protamine sulfate
Rationale: Protamine sulfate is the antidote for heparin toxicity. Vitamin K reverses warfarin
effects. Naloxone reverses opioid overdose, while acetylcysteine treats acetaminophen
toxicity.
, 3. Which laboratory value should the nurse report immediately for a client receiving
chemotherapy?
A. Hemoglobin 12 g/dL
B. Platelet count 240,000/mm³
C. White blood cell count 1,200/mm³
D. Sodium 138 mEq/L
Answer: C. White blood cell count 1,200/mm³
Rationale: A WBC count of 1,200/mm³ indicates severe leukopenia and greatly increases
infection risk. Prompt intervention, protective precautions, and provider notification are
essential.
4. A nurse teaches a client with type 1 diabetes about hypoglycemia. Which symptom
should the client recognize first?
A. Fruity breath odor
B. Increased thirst
C. Shakiness and sweating
D. Deep respirations
Answer: C. Shakiness and sweating
Rationale: Early hypoglycemia activates the sympathetic nervous system, producing
tremors, diaphoresis, tachycardia, and hunger. Fruity breath, excessive thirst, and
Kussmaul respirations are associated with hyperglycemia.
5. Which finding indicates effective pain management after administering IV
morphine?
A. Respiratory rate decreases from 18 to 16 breaths/min.
B. Pain decreases from 8/10 to 3/10.
C. Blood pressure increases slightly.
D. Oxygen saturation decreases to 90%.
Answer: B. Pain decreases from 8/10 to 3/10.
Rationale: Pain relief is best evaluated using the client's self-report. A reduction to 3/10
demonstrates effective analgesia. Oxygen desaturation is an adverse effect requiring
intervention.
, 6. A nurse is caring for a postoperative client. Which assessment finding requires
immediate action?
A. Temperature 99.4°F (37.4°C)
B. Blood pressure 118/74 mm Hg
C. Absent bowel sounds immediately after surgery
D. Oxygen saturation 88% on room air
Answer: D. Oxygen saturation 88% on room air.
Rationale: Hypoxemia is an immediate threat to tissue oxygenation and requires prompt
intervention such as oxygen administration and further assessment. Mild postoperative
ileus is expected initially.
7. Which client is at greatest risk for developing deep vein thrombosis?
A. A client walking after surgery
B. A client on prolonged bed rest after hip surgery
C. A client receiving antibiotics
D. A client with seasonal allergies
Answer: B. A client on prolonged bed rest after hip surgery.
Rationale: Orthopedic surgery and immobility significantly increase venous stasis and clot
formation risk.
8. Which electrolyte imbalance is most likely in a client experiencing prolonged
vomiting?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypermagnesemia
Answer: B. Hypokalemia.
Rationale: Vomiting causes potassium loss and metabolic alkalosis, resulting in
hypokalemia.
