NCLEX RN Comprehensive Practice
Exam 004 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. Bradycardia
B. Warm, flushed skin
C. Rapid, weak pulse
D. Bounding peripheral pulses
Answer: Rapid, weak pulse
Hypovolemic shock causes decreased circulating volume, resulting in
tachycardia, weak peripheral pulses, hypotension, and cool, clammy
skin.
2. A client with heart failure is receiving furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Sodium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: Potassium
Furosemide is a loop diuretic that can cause significant potassium loss,
increasing the risk for dysrhythmias.
, 3. A client taking warfarin should be taught to report which finding
immediately?
A. Mild headache
B. Increased appetite
C. Black, tarry stools
D. Occasional constipation
Answer: Black, tarry stools
Black, tarry stools can indicate gastrointestinal bleeding, a serious
complication of anticoagulant therapy.
4. Which assessment finding is most concerning in a client with
asthma?
A. Expiratory wheezing
B. Respiratory rate of 24/min
C. Anxiety
D. Absent breath sounds
Answer: Absent breath sounds
An absence of breath sounds in a severely asthmatic client may indicate
minimal air movement and impending respiratory failure.
5. A client with diabetes mellitus is awake and experiencing
shakiness, diaphoresis, and confusion. What should the nurse do
first?
A. Administer insulin
B. Obtain a urine specimen
C. Give a rapid-acting source of glucose
D. Encourage exercise
Answer: Give a rapid-acting source of glucose
,These are classic manifestations of hypoglycemia. An alert client should
receive approximately 15 g of rapid-acting carbohydrate.
6. Which finding is expected in a client with hypothyroidism?
A. Tachycardia
B. Heat intolerance
C. Cold intolerance
D. Increased bowel movements
Answer: Cold intolerance
Hypothyroidism decreases metabolic activity and commonly causes
fatigue, weight gain, constipation, bradycardia, and cold intolerance.
7. A nurse is caring for a client with increased intracranial pressure.
Which position is generally appropriate?
A. Flat with legs elevated
B. Trendelenburg
C. Head elevated with neck in neutral alignment
D. Prone with the head turned
Answer: Head elevated with neck in neutral alignment
Head elevation and neutral neck alignment promote venous drainage
from the brain and can help reduce 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. Monitor respiratory status
C. Encourage pursed-lip breathing
D. Oxygen at 15 L/min by nonrebreather mask without an
indication
, Answer: Oxygen at 15 L/min by nonrebreather mask without an
indication
Excessive oxygen administration in some clients with severe COPD can
worsen carbon dioxide retention. Oxygen should be carefully titrated
according to the clinical situation and prescription.
9. A client has a potassium level of 2.8 mEq/L. Which finding should
the nurse anticipate?
A. Hyperactive reflexes
B. Muscle weakness
C. Peaked T waves
D. Severe hypertension
Answer: Muscle weakness
Hypokalemia can cause muscle weakness, fatigue, constipation, and
cardiac dysrhythmias.
10. A nurse is caring for a client with a chest tube. Which finding
requires immediate intervention?
A. Tidaling in the water-seal chamber
B. Small amount of drainage
C. Mild discomfort at insertion site
D. Continuous vigorous bubbling in the water-seal chamber
Answer: Continuous vigorous bubbling in the water-seal chamber
Continuous bubbling in the water-seal chamber usually indicates an air
leak that requires assessment.
11. Which client should the nurse assess first?
A. Client with chronic arthritis reporting pain of 6/10
B. Client requesting assistance with bathing
Exam 004 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. Bradycardia
B. Warm, flushed skin
C. Rapid, weak pulse
D. Bounding peripheral pulses
Answer: Rapid, weak pulse
Hypovolemic shock causes decreased circulating volume, resulting in
tachycardia, weak peripheral pulses, hypotension, and cool, clammy
skin.
2. A client with heart failure is receiving furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Sodium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: Potassium
Furosemide is a loop diuretic that can cause significant potassium loss,
increasing the risk for dysrhythmias.
, 3. A client taking warfarin should be taught to report which finding
immediately?
A. Mild headache
B. Increased appetite
C. Black, tarry stools
D. Occasional constipation
Answer: Black, tarry stools
Black, tarry stools can indicate gastrointestinal bleeding, a serious
complication of anticoagulant therapy.
4. Which assessment finding is most concerning in a client with
asthma?
A. Expiratory wheezing
B. Respiratory rate of 24/min
C. Anxiety
D. Absent breath sounds
Answer: Absent breath sounds
An absence of breath sounds in a severely asthmatic client may indicate
minimal air movement and impending respiratory failure.
5. A client with diabetes mellitus is awake and experiencing
shakiness, diaphoresis, and confusion. What should the nurse do
first?
A. Administer insulin
B. Obtain a urine specimen
C. Give a rapid-acting source of glucose
D. Encourage exercise
Answer: Give a rapid-acting source of glucose
,These are classic manifestations of hypoglycemia. An alert client should
receive approximately 15 g of rapid-acting carbohydrate.
6. Which finding is expected in a client with hypothyroidism?
A. Tachycardia
B. Heat intolerance
C. Cold intolerance
D. Increased bowel movements
Answer: Cold intolerance
Hypothyroidism decreases metabolic activity and commonly causes
fatigue, weight gain, constipation, bradycardia, and cold intolerance.
7. A nurse is caring for a client with increased intracranial pressure.
Which position is generally appropriate?
A. Flat with legs elevated
B. Trendelenburg
C. Head elevated with neck in neutral alignment
D. Prone with the head turned
Answer: Head elevated with neck in neutral alignment
Head elevation and neutral neck alignment promote venous drainage
from the brain and can help reduce 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. Monitor respiratory status
C. Encourage pursed-lip breathing
D. Oxygen at 15 L/min by nonrebreather mask without an
indication
, Answer: Oxygen at 15 L/min by nonrebreather mask without an
indication
Excessive oxygen administration in some clients with severe COPD can
worsen carbon dioxide retention. Oxygen should be carefully titrated
according to the clinical situation and prescription.
9. A client has a potassium level of 2.8 mEq/L. Which finding should
the nurse anticipate?
A. Hyperactive reflexes
B. Muscle weakness
C. Peaked T waves
D. Severe hypertension
Answer: Muscle weakness
Hypokalemia can cause muscle weakness, fatigue, constipation, and
cardiac dysrhythmias.
10. A nurse is caring for a client with a chest tube. Which finding
requires immediate intervention?
A. Tidaling in the water-seal chamber
B. Small amount of drainage
C. Mild discomfort at insertion site
D. Continuous vigorous bubbling in the water-seal chamber
Answer: Continuous vigorous bubbling in the water-seal chamber
Continuous bubbling in the water-seal chamber usually indicates an air
leak that requires assessment.
11. Which client should the nurse assess first?
A. Client with chronic arthritis reporting pain of 6/10
B. Client requesting assistance with bathing
