UWORLD NCLEX-RN PRACTICE TEST 2
QUESTIONS AND ANSWERS
1. A nurse is caring for a client with a history of heart failure who reports sudden onset of
shortness of breath and coughing up pink, frothy sputum. Which action should the nurse take
first?
A. Assess the client’s oxygen saturation
B. Auscultate the client’s lung sounds
C. Prepare to administer a dose of IV furosemide
D. Place the client in high-Fowler’s position
Answer: D
Conceptual Explanation: The client is showing signs of acute pulmonary edema.
Positioning the client in high-Fowler’s is the immediate nursing action to improve
ventilation and decrease venous return, reducing the workload on the heart before
performing further assessments or administering medications.
2. A client is diagnosed with autonomic dysreflexia following a T6 spinal cord injury. Which of
the following is the priority nursing intervention?
A. Administer an antihypertensive medication as ordered
,B. Raise the head of the bed to 90 degrees
C. Check the client’s bladder for distension
D. Assess the skin for pressure areas
Answer: B
Conceptual Explanation: The priority in autonomic dysreflexia is to lower the blood
pressure by utilizing gravity. Raising the head of the bed to a sitting position (90 degrees) is
the first action, followed by identifying and removing the noxious stimulus, such as a full
bladder or impacted bowel.
3. The nurse is reviewing the lab results for a client receiving lithium for bipolar disorder. The
lithium level is 1.8 mEq/L. Which symptom should the nurse expect to find?
A. Mild thirst and polyuria
B. Coarse tremors, ataxia, and confusion
C. Fine hand tremors and weight gain
D. Hyperreflexia and seizures
Answer: B
Conceptual Explanation: A lithium level of 1.8 mEq/L indicates moderate toxicity.
Symptoms include coarse tremors, persistent GI upset, mental confusion, and ataxia. Severe
toxicity (above 2.0-2.5) can lead to seizures and coma.
, 4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via a nasal
cannula at 2 L/min. The client’s SpO2 is 89%. What is the most appropriate nursing action?
A. Continue to monitor the client’s respiratory status
B. Increase the oxygen flow rate to 4 L/min
C. Switch the client to a non-rebreather mask
D. Notify the healthcare provider immediately
Answer: A
Conceptual Explanation: For clients with COPD, a target SpO2 range of 88%–92% is often
acceptable because their drive to breathe is triggered by low oxygen levels rather than high
CO2. An SpO2 of 89% is within the expected range for this condition.
5. A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate. Which
assessment finding requires immediate intervention?
A. Blood pressure of 150/95 mmHg
B. Urine output of 40 mL/hr
C. Respiratory rate of 14 breaths/min
D. Absent deep tendon reflexes
Answer: D
QUESTIONS AND ANSWERS
1. A nurse is caring for a client with a history of heart failure who reports sudden onset of
shortness of breath and coughing up pink, frothy sputum. Which action should the nurse take
first?
A. Assess the client’s oxygen saturation
B. Auscultate the client’s lung sounds
C. Prepare to administer a dose of IV furosemide
D. Place the client in high-Fowler’s position
Answer: D
Conceptual Explanation: The client is showing signs of acute pulmonary edema.
Positioning the client in high-Fowler’s is the immediate nursing action to improve
ventilation and decrease venous return, reducing the workload on the heart before
performing further assessments or administering medications.
2. A client is diagnosed with autonomic dysreflexia following a T6 spinal cord injury. Which of
the following is the priority nursing intervention?
A. Administer an antihypertensive medication as ordered
,B. Raise the head of the bed to 90 degrees
C. Check the client’s bladder for distension
D. Assess the skin for pressure areas
Answer: B
Conceptual Explanation: The priority in autonomic dysreflexia is to lower the blood
pressure by utilizing gravity. Raising the head of the bed to a sitting position (90 degrees) is
the first action, followed by identifying and removing the noxious stimulus, such as a full
bladder or impacted bowel.
3. The nurse is reviewing the lab results for a client receiving lithium for bipolar disorder. The
lithium level is 1.8 mEq/L. Which symptom should the nurse expect to find?
A. Mild thirst and polyuria
B. Coarse tremors, ataxia, and confusion
C. Fine hand tremors and weight gain
D. Hyperreflexia and seizures
Answer: B
Conceptual Explanation: A lithium level of 1.8 mEq/L indicates moderate toxicity.
Symptoms include coarse tremors, persistent GI upset, mental confusion, and ataxia. Severe
toxicity (above 2.0-2.5) can lead to seizures and coma.
, 4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via a nasal
cannula at 2 L/min. The client’s SpO2 is 89%. What is the most appropriate nursing action?
A. Continue to monitor the client’s respiratory status
B. Increase the oxygen flow rate to 4 L/min
C. Switch the client to a non-rebreather mask
D. Notify the healthcare provider immediately
Answer: A
Conceptual Explanation: For clients with COPD, a target SpO2 range of 88%–92% is often
acceptable because their drive to breathe is triggered by low oxygen levels rather than high
CO2. An SpO2 of 89% is within the expected range for this condition.
5. A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate. Which
assessment finding requires immediate intervention?
A. Blood pressure of 150/95 mmHg
B. Urine output of 40 mL/hr
C. Respiratory rate of 14 breaths/min
D. Absent deep tendon reflexes
Answer: D
