NCLEX RN Comprehensive Practice
Exam 003 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 heart failure. Which finding
requires the most immediate intervention?
A. Bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Crackles throughout both lung fields
D. Fatigue with activity
Answer: C. Crackles throughout both lung fields
Rationale: Crackles may indicate acute pulmonary edema, which can
rapidly compromise oxygenation and requires immediate intervention.
2. A client is receiving digoxin. Which finding should cause the nurse
to withhold the medication?
A. Blood pressure 128/76 mmHg
B. Apical pulse 54 beats/min
C. Respiratory rate 18/min
D. Temperature 37°C (98.6°F)
Answer: B. Apical pulse 54 beats/min
,Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60 beats/min and the
provider is notified.
3. A nurse is caring for a client with chronic obstructive pulmonary
disease who is receiving oxygen. Which prescription should the
nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Encourage pursed-lip breathing
C. Oxygen at 10 L/min by nonrebreather mask continuously
D. Position in high-Fowler position
Answer: C. Oxygen at 10 L/min by nonrebreather mask continuously
Rationale: Clients with chronic obstructive pulmonary disease generally
receive carefully titrated oxygen. Excessive oxygen administration can
worsen ventilation-perfusion abnormalities and carbon dioxide
retention in susceptible clients.
4. A client with diabetes mellitus is awake, diaphoretic, and
trembling. The blood glucose is 52 mg/dL (2.9 mmol/L). What
should the nurse do first?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Administer glucagon intramuscularly
D. Encourage the client to ambulate
Answer: B. Give 15 g of rapid-acting carbohydrate
Rationale: An alert client with symptomatic hypoglycemia should
receive approximately 15 g of rapidly absorbed carbohydrate, followed
by reassessment of glucose.
, 5. A client receiving a blood transfusion develops chills, fever, and
low back pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another unit of blood
Answer: B. Stop the transfusion
Rationale: These findings may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the
intravenous line maintained with appropriate solution according to
facility protocol.
6. 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: C. Decreased level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening cerebral function and increased intracranial pressure.
7. A client is prescribed warfarin. Which laboratory test is used to
monitor its therapeutic effect?
A. aPTT
B. INR
C. Platelet count
D. Serum creatinine
Answer: B. INR
, Rationale: The international normalized ratio is used to monitor the
anticoagulant effect of warfarin and guide dosage adjustments.
8. A nurse is teaching a client taking furosemide. Which food is a
good source of potassium?
A. White rice
B. Applesauce
C. Baked potato
D. White bread
Answer: C. Baked potato
Rationale: Potatoes are rich in potassium. Potassium losses can occur
with loop diuretics such as furosemide.
9. A client with a new cast reports severe pain that is not relieved by
prescribed analgesics. The toes are pale and cool. What should
the nurse do?
A. Elevate the extremity and reassess in 4 hours
B. Apply heat over the cast
C. Notify the provider immediately
D. Encourage active exercise of the affected limb
Answer: C. Notify the provider immediately
Rationale: Severe unrelieved pain with pallor and coolness can indicate
impaired circulation or compartment syndrome, which requires
immediate evaluation.
10. A nurse is caring for a client after thyroidectomy. Which
finding requires immediate action?
A. Mild incisional discomfort
B. Hoarse voice immediately after surgery
Exam 003 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
1. A nurse is assessing a client with heart failure. Which finding
requires the most immediate intervention?
A. Bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Crackles throughout both lung fields
D. Fatigue with activity
Answer: C. Crackles throughout both lung fields
Rationale: Crackles may indicate acute pulmonary edema, which can
rapidly compromise oxygenation and requires immediate intervention.
2. A client is receiving digoxin. Which finding should cause the nurse
to withhold the medication?
A. Blood pressure 128/76 mmHg
B. Apical pulse 54 beats/min
C. Respiratory rate 18/min
D. Temperature 37°C (98.6°F)
Answer: B. Apical pulse 54 beats/min
,Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60 beats/min and the
provider is notified.
3. A nurse is caring for a client with chronic obstructive pulmonary
disease who is receiving oxygen. Which prescription should the
nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Encourage pursed-lip breathing
C. Oxygen at 10 L/min by nonrebreather mask continuously
D. Position in high-Fowler position
Answer: C. Oxygen at 10 L/min by nonrebreather mask continuously
Rationale: Clients with chronic obstructive pulmonary disease generally
receive carefully titrated oxygen. Excessive oxygen administration can
worsen ventilation-perfusion abnormalities and carbon dioxide
retention in susceptible clients.
4. A client with diabetes mellitus is awake, diaphoretic, and
trembling. The blood glucose is 52 mg/dL (2.9 mmol/L). What
should the nurse do first?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Administer glucagon intramuscularly
D. Encourage the client to ambulate
Answer: B. Give 15 g of rapid-acting carbohydrate
Rationale: An alert client with symptomatic hypoglycemia should
receive approximately 15 g of rapidly absorbed carbohydrate, followed
by reassessment of glucose.
, 5. A client receiving a blood transfusion develops chills, fever, and
low back pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another unit of blood
Answer: B. Stop the transfusion
Rationale: These findings may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the
intravenous line maintained with appropriate solution according to
facility protocol.
6. 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: C. Decreased level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening cerebral function and increased intracranial pressure.
7. A client is prescribed warfarin. Which laboratory test is used to
monitor its therapeutic effect?
A. aPTT
B. INR
C. Platelet count
D. Serum creatinine
Answer: B. INR
, Rationale: The international normalized ratio is used to monitor the
anticoagulant effect of warfarin and guide dosage adjustments.
8. A nurse is teaching a client taking furosemide. Which food is a
good source of potassium?
A. White rice
B. Applesauce
C. Baked potato
D. White bread
Answer: C. Baked potato
Rationale: Potatoes are rich in potassium. Potassium losses can occur
with loop diuretics such as furosemide.
9. A client with a new cast reports severe pain that is not relieved by
prescribed analgesics. The toes are pale and cool. What should
the nurse do?
A. Elevate the extremity and reassess in 4 hours
B. Apply heat over the cast
C. Notify the provider immediately
D. Encourage active exercise of the affected limb
Answer: C. Notify the provider immediately
Rationale: Severe unrelieved pain with pallor and coolness can indicate
impaired circulation or compartment syndrome, which requires
immediate evaluation.
10. A nurse is caring for a client after thyroidectomy. Which
finding requires immediate action?
A. Mild incisional discomfort
B. Hoarse voice immediately after surgery
