NCLEX-RN Exam Preparation –
Complete Exam 2 with Verified Answers
(2026 Edition)
Question 1: A nurse is caring for a client with acute kidney injury (AKI) who is in the oliguric
phase. Which laboratory finding should the nurse expect?
A) Decreased serum potassium
B) Increased serum creatinine
C) Decreased serum phosphorus
D) Increased serum calcium
Answer: B) Increased serum creatinine
Rationale: In the oliguric phase of AKI, urine output decreases to less than 400 mL/day, leading
to the accumulation of metabolic wastes. Creatinine and blood urea nitrogen (BUN) levels rise
as the kidneys fail to excrete these waste products. The nurse should monitor the client's fluid
and electrolyte balance, including hyperkalemia, hyperphosphatemia, and hypocalcemia.
Question 2: A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen
therapy. Which oxygen delivery method is most appropriate for this client?
A) Non-rebreather mask at 15 L/min
B) Simple face mask at 10 L/min
C) Venturi mask at 24% oxygen
D) Nasal cannula at 6 L/min
Answer: C) Venturi mask at 24% oxygen
Rationale: The Venturi mask delivers a precise concentration of oxygen, which is essential for
clients with COPD who have a hypoxic drive to breathe. High oxygen concentrations can
suppress the respiratory drive in these clients. The Venturi mask ensures accurate oxygen
delivery, reducing the risk of respiratory depression.
Question 3: A nurse is preparing to administer a blood transfusion to a client. Which action
should the nurse take first?
,A) Verify the client's blood type with another nurse
B) Obtain baseline vital signs
C) Prime the blood tubing with normal saline
D) Ensure the client has signed a consent form
Answer: A) Verify the client's blood type with another nurse
Rationale: Verification of blood product with another nurse is the most critical safety measure to
prevent transfusion reactions. This includes checking the client's identification, blood type, Rh
factor, unit number, and expiration date. The two-nurse verification system is a standard of care
to prevent ABO incompatibility reactions, which can be fatal.
Question 4: A client with heart failure is prescribed digoxin. Which finding indicates digoxin
toxicity?
A) Heart rate of 60 beats per minute
B) Blood pressure of 140/90 mmHg
C) Visual disturbances with yellow-green halos
D) Peripheral edema
Answer: C) Visual disturbances with yellow-green halos
Rationale: Yellow-green halos around lights (xanthopsia) is a classic sign of digoxin toxicity.
Other signs include nausea, vomiting, confusion, and cardiac arrhythmias. The nurse should
assess the client's pulse before administration, hold the dose if the heart rate is less than 60
bpm, and monitor for signs of toxicity including visual changes.
Question 5: A client with diabetes mellitus type 2 is prescribed metformin. Which side effect
should the nurse monitor for?
A) Hypoglycemia
B) Lactic acidosis
C) Weight gain
D) Hyperglycemia
Answer: B) Lactic acidosis
Rationale: Metformin can cause lactic acidosis, a rare but serious side effect, especially in clients
with renal impairment, hepatic disease, or conditions that cause hypoxia. The nurse should
monitor for symptoms including muscle pain, weakness, difficulty breathing, and
gastrointestinal distress. Renal function should be assessed before and during therapy.
,Question 6: A nurse is assessing a client's wound. Which finding indicates the wound is
infected?
A) Serous drainage
B) Pink granulation tissue
C) Foul-smelling purulent drainage
D) Edges approximated
Answer: C) Foul-smelling purulent drainage
Rationale: Purulent drainage (pus) with a foul odor is a classic sign of wound infection. Other
signs include erythema, warmth, swelling, and pain. Serous drainage is normal in the
inflammatory phase, and pink granulation tissue indicates healing. The nurse should obtain a
wound culture and notify the healthcare provider for antibiotic therapy.
Question 7: A client is prescribed warfarin. Which dietary instruction should the nurse include?
A) Increase intake of dark green leafy vegetables
B) Maintain consistent intake of vitamin K-rich foods
C) Avoid all foods containing vitamin K
D) Increase intake of foods high in vitamin C
Answer: B) Maintain consistent intake of vitamin K-rich foods
Rationale: Warfarin works by inhibiting vitamin K-dependent clotting factors. Sudden changes in
vitamin K intake can alter the INR and affect anticoagulation. Clients should maintain a
consistent intake of vitamin K-rich foods rather than avoiding them completely. The healthcare
provider adjusts the warfarin dose based on the INR, and consistent dietary patterns help
maintain therapeutic levels.
Question 8: A nurse is caring for a client with a nasogastric (NG) tube. Which action should the
nurse take to verify proper tube placement?
A) Check the pH of gastric aspirate
B) Auscultate for air insufflation
C) Measure the length of the external portion of the tube
D) All of the above
Answer: D) All of the above
Rationale: Verification of NG tube placement should include measuring pH of gastric aspirate
(pH ≤ 5), measuring the external length of the tube, and observing the color and consistency of
, aspirate. Auscultation of air insufflation is controversial and not considered reliable.
Radiographic confirmation is the gold standard for placement verification.
Question 9: A client is admitted with diabetic ketoacidosis (DKA). Which finding should the
nurse expect?
A) Serum pH of 7.40
B) Serum bicarbonate of 22 mEq/L
C) Serum glucose of 450 mg/dL
D) Serum potassium of 5.5 mEq/L
Answer: C) Serum glucose of 450 mg/dL
Rationale: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia (blood glucose >250
mg/dL), metabolic acidosis (pH <7.35, bicarbonate <15 mEq/L), and ketonemia. The nurse
should monitor the client's blood glucose, electrolytes, and acid-base status. Treatment includes
insulin, fluid replacement, and correction of electrolyte imbalances.
Question 10: A nurse is assessing a client with a head injury. Which finding indicates increased
intracranial pressure (ICP)?
A) Pupils equal and reactive to light
B) Bilateral Babinski sign
C) Cushing's triad
D) Flaccid muscle tone
Answer: C) Cushing's triad
Rationale: Cushing's triad consists of hypertension, bradycardia, and irregular respirations. This
indicates increased intracranial pressure and requires immediate intervention. The nurse should
monitor the client's neurological status, including level of consciousness, pupillary response, and
vital signs. Increased ICP can lead to brain herniation, a life-threatening emergency.
Question 11: A client with asthma is prescribed albuterol. Which finding indicates the
medication is effective?
A) Decreased heart rate
B) Decreased respiratory rate with improved breath sounds
C) Increased oxygen saturation with decreased wheezing
D) Increased respiratory rate with improved breath sounds
Complete Exam 2 with Verified Answers
(2026 Edition)
Question 1: A nurse is caring for a client with acute kidney injury (AKI) who is in the oliguric
phase. Which laboratory finding should the nurse expect?
A) Decreased serum potassium
B) Increased serum creatinine
C) Decreased serum phosphorus
D) Increased serum calcium
Answer: B) Increased serum creatinine
Rationale: In the oliguric phase of AKI, urine output decreases to less than 400 mL/day, leading
to the accumulation of metabolic wastes. Creatinine and blood urea nitrogen (BUN) levels rise
as the kidneys fail to excrete these waste products. The nurse should monitor the client's fluid
and electrolyte balance, including hyperkalemia, hyperphosphatemia, and hypocalcemia.
Question 2: A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen
therapy. Which oxygen delivery method is most appropriate for this client?
A) Non-rebreather mask at 15 L/min
B) Simple face mask at 10 L/min
C) Venturi mask at 24% oxygen
D) Nasal cannula at 6 L/min
Answer: C) Venturi mask at 24% oxygen
Rationale: The Venturi mask delivers a precise concentration of oxygen, which is essential for
clients with COPD who have a hypoxic drive to breathe. High oxygen concentrations can
suppress the respiratory drive in these clients. The Venturi mask ensures accurate oxygen
delivery, reducing the risk of respiratory depression.
Question 3: A nurse is preparing to administer a blood transfusion to a client. Which action
should the nurse take first?
,A) Verify the client's blood type with another nurse
B) Obtain baseline vital signs
C) Prime the blood tubing with normal saline
D) Ensure the client has signed a consent form
Answer: A) Verify the client's blood type with another nurse
Rationale: Verification of blood product with another nurse is the most critical safety measure to
prevent transfusion reactions. This includes checking the client's identification, blood type, Rh
factor, unit number, and expiration date. The two-nurse verification system is a standard of care
to prevent ABO incompatibility reactions, which can be fatal.
Question 4: A client with heart failure is prescribed digoxin. Which finding indicates digoxin
toxicity?
A) Heart rate of 60 beats per minute
B) Blood pressure of 140/90 mmHg
C) Visual disturbances with yellow-green halos
D) Peripheral edema
Answer: C) Visual disturbances with yellow-green halos
Rationale: Yellow-green halos around lights (xanthopsia) is a classic sign of digoxin toxicity.
Other signs include nausea, vomiting, confusion, and cardiac arrhythmias. The nurse should
assess the client's pulse before administration, hold the dose if the heart rate is less than 60
bpm, and monitor for signs of toxicity including visual changes.
Question 5: A client with diabetes mellitus type 2 is prescribed metformin. Which side effect
should the nurse monitor for?
A) Hypoglycemia
B) Lactic acidosis
C) Weight gain
D) Hyperglycemia
Answer: B) Lactic acidosis
Rationale: Metformin can cause lactic acidosis, a rare but serious side effect, especially in clients
with renal impairment, hepatic disease, or conditions that cause hypoxia. The nurse should
monitor for symptoms including muscle pain, weakness, difficulty breathing, and
gastrointestinal distress. Renal function should be assessed before and during therapy.
,Question 6: A nurse is assessing a client's wound. Which finding indicates the wound is
infected?
A) Serous drainage
B) Pink granulation tissue
C) Foul-smelling purulent drainage
D) Edges approximated
Answer: C) Foul-smelling purulent drainage
Rationale: Purulent drainage (pus) with a foul odor is a classic sign of wound infection. Other
signs include erythema, warmth, swelling, and pain. Serous drainage is normal in the
inflammatory phase, and pink granulation tissue indicates healing. The nurse should obtain a
wound culture and notify the healthcare provider for antibiotic therapy.
Question 7: A client is prescribed warfarin. Which dietary instruction should the nurse include?
A) Increase intake of dark green leafy vegetables
B) Maintain consistent intake of vitamin K-rich foods
C) Avoid all foods containing vitamin K
D) Increase intake of foods high in vitamin C
Answer: B) Maintain consistent intake of vitamin K-rich foods
Rationale: Warfarin works by inhibiting vitamin K-dependent clotting factors. Sudden changes in
vitamin K intake can alter the INR and affect anticoagulation. Clients should maintain a
consistent intake of vitamin K-rich foods rather than avoiding them completely. The healthcare
provider adjusts the warfarin dose based on the INR, and consistent dietary patterns help
maintain therapeutic levels.
Question 8: A nurse is caring for a client with a nasogastric (NG) tube. Which action should the
nurse take to verify proper tube placement?
A) Check the pH of gastric aspirate
B) Auscultate for air insufflation
C) Measure the length of the external portion of the tube
D) All of the above
Answer: D) All of the above
Rationale: Verification of NG tube placement should include measuring pH of gastric aspirate
(pH ≤ 5), measuring the external length of the tube, and observing the color and consistency of
, aspirate. Auscultation of air insufflation is controversial and not considered reliable.
Radiographic confirmation is the gold standard for placement verification.
Question 9: A client is admitted with diabetic ketoacidosis (DKA). Which finding should the
nurse expect?
A) Serum pH of 7.40
B) Serum bicarbonate of 22 mEq/L
C) Serum glucose of 450 mg/dL
D) Serum potassium of 5.5 mEq/L
Answer: C) Serum glucose of 450 mg/dL
Rationale: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia (blood glucose >250
mg/dL), metabolic acidosis (pH <7.35, bicarbonate <15 mEq/L), and ketonemia. The nurse
should monitor the client's blood glucose, electrolytes, and acid-base status. Treatment includes
insulin, fluid replacement, and correction of electrolyte imbalances.
Question 10: A nurse is assessing a client with a head injury. Which finding indicates increased
intracranial pressure (ICP)?
A) Pupils equal and reactive to light
B) Bilateral Babinski sign
C) Cushing's triad
D) Flaccid muscle tone
Answer: C) Cushing's triad
Rationale: Cushing's triad consists of hypertension, bradycardia, and irregular respirations. This
indicates increased intracranial pressure and requires immediate intervention. The nurse should
monitor the client's neurological status, including level of consciousness, pupillary response, and
vital signs. Increased ICP can lead to brain herniation, a life-threatening emergency.
Question 11: A client with asthma is prescribed albuterol. Which finding indicates the
medication is effective?
A) Decreased heart rate
B) Decreased respiratory rate with improved breath sounds
C) Increased oxygen saturation with decreased wheezing
D) Increased respiratory rate with improved breath sounds
