NCLEX RN Comprehensive Practice
Exam 002 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
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1. A nurse is assessing a client with hypovolemic shock. Which finding
should the nurse expect?
A. Bounding pulse
B. Bradycardia
C. Cool, clammy skin
D. Warm, flushed skin
Answer: Cool, clammy skin
Rationale: Hypovolemic shock causes decreased circulating volume,
resulting in peripheral vasoconstriction, cool clammy skin,
tachycardia, and hypotension.
2. A client with heart failure reports increasing shortness of breath.
Which assessment finding requires immediate intervention?
A. Weight gain of 1 lb in 24 hours
B. Bilateral crackles
C. Mild ankle edema
D. Fatigue with activity
Answer: Bilateral crackles
Rationale: Crackles may indicate pulmonary edema from worsening
heart failure and require prompt intervention to improve oxygenation.
,3. Which finding is most characteristic of diabetic ketoacidosis?
A. Bradycardia
B. Kussmaul respirations
C. Hypoglycemia
D. Decreased thirst
Answer: Kussmaul respirations
Rationale: Kussmaul respirations are deep, rapid respirations that
compensate for metabolic acidosis associated with diabetic
ketoacidosis.
4. A nurse is caring for a client receiving digoxin. Which finding should
cause the nurse to hold the medication and notify the provider?
A. Apical pulse of 54/min
B. Respiratory rate of 18/min
C. Blood pressure of 128/76 mm Hg
D. Temperature of 98.6°F (37°C)
Answer: Apical pulse of 54/min
Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60/min unless
otherwise prescribed.
5. Which intervention is appropriate for a client experiencing a
seizure?
A. Insert a tongue blade
B. Restrain the extremities
C. Place the client on the side
D. Offer oral fluids
Answer: Place the client on the side
,Rationale: Side positioning helps maintain the airway and allows
secretions to drain. The nurse should not restrain the client or place
objects in the mouth.
6. A client receiving a blood transfusion develops chills, fever, and
back pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Increase the infusion rate
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain can indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately.
7. Which assessment finding is most concerning in a client with
increased intracranial pressure?
A. Headache
B. Vomiting
C. Decreased level of consciousness
D. Photophobia
Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is a significant indicator
of worsening neurologic status and increased intracranial pressure.
8. A client with chronic obstructive pulmonary disease is receiving
oxygen. Which prescription should the nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Oxygen adjusted to maintain prescribed saturation
C. Continuous respiratory assessment
, D. Oxygen at 15 L/min by nonrebreather mask without an acute
indication
Answer: Oxygen at 15 L/min by nonrebreather mask without an acute
indication
Rationale: Clients with chronic obstructive pulmonary disease require
carefully titrated oxygen. Excessive oxygen administration without an
acute indication can worsen carbon dioxide retention in some clients.
9. Which laboratory value should the nurse monitor most closely in a
client receiving warfarin?
A. INR
B. Sodium
C. Hemoglobin A1C
D. Serum amylase
Answer: INR
Rationale: The international normalized ratio is used to monitor the
therapeutic effect and bleeding risk of warfarin.
10. A client taking furosemide is at greatest risk for which electrolyte
imbalance?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypermagnesemia
Answer: Hypokalemia
Rationale: Furosemide is a loop diuretic that increases urinary
potassium loss and can cause hypokalemia.
11. Which finding is expected in a client experiencing hypoglycemia?
Exam 002 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
1. A nurse is assessing a client with hypovolemic shock. Which finding
should the nurse expect?
A. Bounding pulse
B. Bradycardia
C. Cool, clammy skin
D. Warm, flushed skin
Answer: Cool, clammy skin
Rationale: Hypovolemic shock causes decreased circulating volume,
resulting in peripheral vasoconstriction, cool clammy skin,
tachycardia, and hypotension.
2. A client with heart failure reports increasing shortness of breath.
Which assessment finding requires immediate intervention?
A. Weight gain of 1 lb in 24 hours
B. Bilateral crackles
C. Mild ankle edema
D. Fatigue with activity
Answer: Bilateral crackles
Rationale: Crackles may indicate pulmonary edema from worsening
heart failure and require prompt intervention to improve oxygenation.
,3. Which finding is most characteristic of diabetic ketoacidosis?
A. Bradycardia
B. Kussmaul respirations
C. Hypoglycemia
D. Decreased thirst
Answer: Kussmaul respirations
Rationale: Kussmaul respirations are deep, rapid respirations that
compensate for metabolic acidosis associated with diabetic
ketoacidosis.
4. A nurse is caring for a client receiving digoxin. Which finding should
cause the nurse to hold the medication and notify the provider?
A. Apical pulse of 54/min
B. Respiratory rate of 18/min
C. Blood pressure of 128/76 mm Hg
D. Temperature of 98.6°F (37°C)
Answer: Apical pulse of 54/min
Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60/min unless
otherwise prescribed.
5. Which intervention is appropriate for a client experiencing a
seizure?
A. Insert a tongue blade
B. Restrain the extremities
C. Place the client on the side
D. Offer oral fluids
Answer: Place the client on the side
,Rationale: Side positioning helps maintain the airway and allows
secretions to drain. The nurse should not restrain the client or place
objects in the mouth.
6. A client receiving a blood transfusion develops chills, fever, and
back pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Increase the infusion rate
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain can indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately.
7. Which assessment finding is most concerning in a client with
increased intracranial pressure?
A. Headache
B. Vomiting
C. Decreased level of consciousness
D. Photophobia
Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is a significant indicator
of worsening neurologic status and increased intracranial pressure.
8. A client with chronic obstructive pulmonary disease is receiving
oxygen. Which prescription should the nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Oxygen adjusted to maintain prescribed saturation
C. Continuous respiratory assessment
, D. Oxygen at 15 L/min by nonrebreather mask without an acute
indication
Answer: Oxygen at 15 L/min by nonrebreather mask without an acute
indication
Rationale: Clients with chronic obstructive pulmonary disease require
carefully titrated oxygen. Excessive oxygen administration without an
acute indication can worsen carbon dioxide retention in some clients.
9. Which laboratory value should the nurse monitor most closely in a
client receiving warfarin?
A. INR
B. Sodium
C. Hemoglobin A1C
D. Serum amylase
Answer: INR
Rationale: The international normalized ratio is used to monitor the
therapeutic effect and bleeding risk of warfarin.
10. A client taking furosemide is at greatest risk for which electrolyte
imbalance?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypermagnesemia
Answer: Hypokalemia
Rationale: Furosemide is a loop diuretic that increases urinary
potassium loss and can cause hypokalemia.
11. Which finding is expected in a client experiencing hypoglycemia?
