NCLEX RN Comprehensive Practice Exam
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
1. A nurse is caring for a client who suddenly develops severe shortness of
breath, chest pain, and an oxygen saturation of 86% on room air. Which
action should the nurse take first?
A. Obtain a complete health history
B. Encourage the client to ambulate
C. Apply oxygen and assess respiratory status
D. Administer the client's scheduled oral medication
Answer: C. Apply oxygen and assess respiratory status
Rationale: The client is demonstrating acute hypoxemia and respiratory
compromise. Airway and breathing are immediate priorities. Applying supplemental
oxygen while rapidly assessing respiratory status addresses the most urgent
problem. A complete history and routine medications can wait until the client's
oxygenation and breathing are stabilized.
2. A client with heart failure reports a 2-kg weight gain over the past 2 days.
Which finding should the nurse recognize as most concerning?
A. Increased appetite
B. Bilateral ankle edema
C. Dry skin
D. Increased urinary frequency
Answer: B. Bilateral ankle edema
,Rationale: Rapid weight gain in a client with heart failure commonly indicates fluid
retention. Peripheral edema is an important manifestation of worsening volume
overload and may occur with pulmonary congestion. The nurse should assess
respiratory status, lung sounds, oxygenation, and other signs of decompensated
heart failure.
3. A nurse is preparing to administer digoxin to an adult client. The client's
apical pulse is 54 beats/min. What should the nurse do?
A. Administer the medication as prescribed
B. Give the medication with an antacid
C. Hold the medication and notify the provider
D. Ask the client to exercise before administration
Answer: C. Hold the medication and notify the provider
Rationale: Digoxin can decrease the heart rate. An adult apical pulse below the
commonly accepted threshold of 60 beats/min requires the nurse to withhold the
medication and notify the provider according to institutional policy. Administering
digoxin despite significant bradycardia could worsen the client's condition.
4. A client with chronic obstructive pulmonary disease is receiving oxygen
therapy. Which nursing intervention is most appropriate?
A. Use the highest possible oxygen flow rate
B. Administer oxygen as prescribed and monitor respiratory status
C. Discontinue oxygen whenever the client becomes dyspneic
D. Encourage prolonged breath-holding exercises
Answer: B. Administer oxygen as prescribed and monitor respiratory status
Rationale: Clients with COPD may require carefully titrated oxygen therapy. The
nurse should administer oxygen according to the prescription and monitor oxygen
saturation, respiratory rate, effort, mental status, and overall clinical response.
Excessive oxygen administration can contribute to worsening carbon dioxide
retention in some clients, so oxygen should be titrated appropriately rather than
automatically maximized.
, 5. A postoperative client suddenly becomes restless and confused. The oxygen
saturation is 88%. Which action is the nurse's priority?
A. Document the client's behavior
B. Administer a prescribed sedative
C. Assess airway and breathing and provide oxygen as indicated
D. Encourage the client to sleep
Answer: C. Assess airway and breathing and provide oxygen as indicated
Rationale: Restlessness and confusion may be early manifestations of hypoxemia.
The nurse should immediately assess airway and breathing and address impaired
oxygenation. Sedating a potentially hypoxemic client could worsen respiratory
depression. Documentation is important but should occur after immediate
stabilization.
6. A nurse is teaching a client who has asthma about using a prescribed short-
acting beta2-agonist inhaler. Which statement indicates correct
understanding?
A. “I will use it for immediate relief of acute bronchospasm.”
B. “I should use it only once every month.”
C. “It will permanently cure my asthma.”
D. “I should stop all controller medications when I use it.”
Answer: A. “I will use it for immediate relief of acute bronchospasm.”
Rationale: Short-acting beta2-agonists such as albuterol are commonly used as
rescue medications for rapid relief of bronchospasm. They do not cure asthma and
should not automatically replace prescribed controller therapy. Frequent need for
rescue medication may indicate inadequate asthma control and should be reported.
7. A client with pneumonia has a temperature of 39.2°C (102.6°F), respiratory
rate of 30/min, and oxygen saturation of 90%. Which finding requires the
most immediate attention?
A. Fever
B. Tachypnea with low oxygen saturation
, C. Productive cough
D. Fatigue
Answer: B. Tachypnea with low oxygen saturation
Rationale: Impaired oxygenation and increased work of breathing are immediate
priorities. The client's tachypnea and low oxygen saturation suggest respiratory
compromise. The nurse should assess airway and breathing, provide oxygen as
prescribed, position the client appropriately, and notify the provider or rapid
response team if the client's condition deteriorates.
8. A client is admitted with suspected pulmonary embolism. Which assessment
finding is most characteristic?
A. Sudden dyspnea and pleuritic chest pain
B. Gradual weight gain
C. Increased appetite
D. Bilateral hearing loss
Answer: A. Sudden dyspnea and pleuritic chest pain
Rationale: Pulmonary embolism may present suddenly with dyspnea, pleuritic chest
pain, tachypnea, tachycardia, hypoxemia, anxiety, and sometimes hemoptysis. This
is a potentially life-threatening emergency requiring rapid assessment and
intervention.
9. A client with a tracheostomy has noisy respirations and increasing
respiratory effort. What should the nurse do first?
A. Offer oral fluids
B. Assess the tracheostomy for obstruction and suction as indicated
C. Place the client flat
D. Remove the tracheostomy tube immediately without assessment
Answer: B. Assess the tracheostomy for obstruction and suction as indicated
Rationale: Noisy respirations and increased work of breathing may indicate
retained secretions or tracheostomy obstruction. The nurse should rapidly assess
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
1. A nurse is caring for a client who suddenly develops severe shortness of
breath, chest pain, and an oxygen saturation of 86% on room air. Which
action should the nurse take first?
A. Obtain a complete health history
B. Encourage the client to ambulate
C. Apply oxygen and assess respiratory status
D. Administer the client's scheduled oral medication
Answer: C. Apply oxygen and assess respiratory status
Rationale: The client is demonstrating acute hypoxemia and respiratory
compromise. Airway and breathing are immediate priorities. Applying supplemental
oxygen while rapidly assessing respiratory status addresses the most urgent
problem. A complete history and routine medications can wait until the client's
oxygenation and breathing are stabilized.
2. A client with heart failure reports a 2-kg weight gain over the past 2 days.
Which finding should the nurse recognize as most concerning?
A. Increased appetite
B. Bilateral ankle edema
C. Dry skin
D. Increased urinary frequency
Answer: B. Bilateral ankle edema
,Rationale: Rapid weight gain in a client with heart failure commonly indicates fluid
retention. Peripheral edema is an important manifestation of worsening volume
overload and may occur with pulmonary congestion. The nurse should assess
respiratory status, lung sounds, oxygenation, and other signs of decompensated
heart failure.
3. A nurse is preparing to administer digoxin to an adult client. The client's
apical pulse is 54 beats/min. What should the nurse do?
A. Administer the medication as prescribed
B. Give the medication with an antacid
C. Hold the medication and notify the provider
D. Ask the client to exercise before administration
Answer: C. Hold the medication and notify the provider
Rationale: Digoxin can decrease the heart rate. An adult apical pulse below the
commonly accepted threshold of 60 beats/min requires the nurse to withhold the
medication and notify the provider according to institutional policy. Administering
digoxin despite significant bradycardia could worsen the client's condition.
4. A client with chronic obstructive pulmonary disease is receiving oxygen
therapy. Which nursing intervention is most appropriate?
A. Use the highest possible oxygen flow rate
B. Administer oxygen as prescribed and monitor respiratory status
C. Discontinue oxygen whenever the client becomes dyspneic
D. Encourage prolonged breath-holding exercises
Answer: B. Administer oxygen as prescribed and monitor respiratory status
Rationale: Clients with COPD may require carefully titrated oxygen therapy. The
nurse should administer oxygen according to the prescription and monitor oxygen
saturation, respiratory rate, effort, mental status, and overall clinical response.
Excessive oxygen administration can contribute to worsening carbon dioxide
retention in some clients, so oxygen should be titrated appropriately rather than
automatically maximized.
, 5. A postoperative client suddenly becomes restless and confused. The oxygen
saturation is 88%. Which action is the nurse's priority?
A. Document the client's behavior
B. Administer a prescribed sedative
C. Assess airway and breathing and provide oxygen as indicated
D. Encourage the client to sleep
Answer: C. Assess airway and breathing and provide oxygen as indicated
Rationale: Restlessness and confusion may be early manifestations of hypoxemia.
The nurse should immediately assess airway and breathing and address impaired
oxygenation. Sedating a potentially hypoxemic client could worsen respiratory
depression. Documentation is important but should occur after immediate
stabilization.
6. A nurse is teaching a client who has asthma about using a prescribed short-
acting beta2-agonist inhaler. Which statement indicates correct
understanding?
A. “I will use it for immediate relief of acute bronchospasm.”
B. “I should use it only once every month.”
C. “It will permanently cure my asthma.”
D. “I should stop all controller medications when I use it.”
Answer: A. “I will use it for immediate relief of acute bronchospasm.”
Rationale: Short-acting beta2-agonists such as albuterol are commonly used as
rescue medications for rapid relief of bronchospasm. They do not cure asthma and
should not automatically replace prescribed controller therapy. Frequent need for
rescue medication may indicate inadequate asthma control and should be reported.
7. A client with pneumonia has a temperature of 39.2°C (102.6°F), respiratory
rate of 30/min, and oxygen saturation of 90%. Which finding requires the
most immediate attention?
A. Fever
B. Tachypnea with low oxygen saturation
, C. Productive cough
D. Fatigue
Answer: B. Tachypnea with low oxygen saturation
Rationale: Impaired oxygenation and increased work of breathing are immediate
priorities. The client's tachypnea and low oxygen saturation suggest respiratory
compromise. The nurse should assess airway and breathing, provide oxygen as
prescribed, position the client appropriately, and notify the provider or rapid
response team if the client's condition deteriorates.
8. A client is admitted with suspected pulmonary embolism. Which assessment
finding is most characteristic?
A. Sudden dyspnea and pleuritic chest pain
B. Gradual weight gain
C. Increased appetite
D. Bilateral hearing loss
Answer: A. Sudden dyspnea and pleuritic chest pain
Rationale: Pulmonary embolism may present suddenly with dyspnea, pleuritic chest
pain, tachypnea, tachycardia, hypoxemia, anxiety, and sometimes hemoptysis. This
is a potentially life-threatening emergency requiring rapid assessment and
intervention.
9. A client with a tracheostomy has noisy respirations and increasing
respiratory effort. What should the nurse do first?
A. Offer oral fluids
B. Assess the tracheostomy for obstruction and suction as indicated
C. Place the client flat
D. Remove the tracheostomy tube immediately without assessment
Answer: B. Assess the tracheostomy for obstruction and suction as indicated
Rationale: Noisy respirations and increased work of breathing may indicate
retained secretions or tracheostomy obstruction. The nurse should rapidly assess
