NCLEX RN Comprehensive
Practice Exam 009 Questions
And Correct Answers (Verified
Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A nurse is assessing a client with hypovolemic shock. Which
finding requires immediate intervention?
A. Blood pressure 88/54 mm Hg
B. Urine output 20 mL/hr
C. Heart rate 124/min
D. Cool, clammy skin
Answer: Blood pressure 88/54 mm Hg
Rationale: Hypotension indicates inadequate tissue perfusion and is a
critical finding in hypovolemic shock requiring immediate treatment.
2. A client receiving digoxin has an apical pulse of 52/min. What
should the nurse do?
A. Administer the medication
B. Give the medication with food
C. Hold the medication
D. Recheck the pulse after administration
Answer: Hold the medication
,Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60/min and the provider
is notified.
3. Which assessment finding is most characteristic of left-sided heart
failure?
A. Peripheral edema
B. Jugular venous distention
C. Ascites
D. Crackles in the lungs
Answer: Crackles in the lungs
Rationale: Left-sided heart failure causes pulmonary congestion,
producing crackles, dyspnea, and orthopnea.
4. A nurse is teaching a client prescribed warfarin. Which statement
indicates correct understanding?
A. "I should avoid all foods containing vitamin K."
B. "I can take aspirin whenever I have a headache."
C. "I should keep my intake of vitamin K-containing foods consistent."
D. "I do not need blood tests while taking this medication."
Answer: "I should keep my intake of vitamin K-containing foods
consistent."
Rationale: Vitamin K affects warfarin activity. Clients should maintain a
consistent intake rather than completely avoiding vitamin K.
5. Which laboratory value should the nurse monitor for a client
receiving heparin therapy?
A. INR
B. Hemoglobin A1c
,C. aPTT
D. Serum sodium
Answer: aPTT
Rationale: Activated partial thromboplastin time is commonly used to
monitor unfractionated heparin therapy.
6. A client with chronic obstructive pulmonary disease is receiving
oxygen. Which prescription is most appropriate?
A. 15 L/min by nonrebreather mask
B. Low-flow oxygen as prescribed
C. Oxygen at maximum concentration continuously
D. Discontinue oxygen if respiratory rate increases
Answer: Low-flow oxygen as prescribed
Rationale: Clients with chronic obstructive pulmonary disease may
require carefully titrated oxygen to maintain adequate oxygenation.
7. Which finding is expected in a client experiencing diabetic
ketoacidosis?
A. Bradycardia
B. Kussmaul respirations
C. Severe hypoglycemia
D. Decreased serum ketones
Answer: Kussmaul respirations
Rationale: Kussmaul respirations are deep, rapid respirations that
compensate for metabolic acidosis in diabetic ketoacidosis.
8. A nurse is caring for a client with hypoglycemia. Which finding is
expected?
, A. Warm, dry skin
B. Fruity breath
C. Diaphoresis and tremors
D. Kussmaul respirations
Answer: Diaphoresis and tremors
Rationale: Adrenergic manifestations of hypoglycemia include sweating,
tremors, tachycardia, anxiety, and hunger.
9. A conscious client has a blood glucose level of 54 mg/dL. What
should the nurse provide?
A. Regular insulin
B. Approximately 15 g of rapid-acting carbohydrate
C. A high-protein meal only
D. Long-acting insulin
Answer: Approximately 15 g of rapid-acting carbohydrate
Rationale: The 15-15 approach is commonly used: provide about 15 g of
rapid carbohydrate and recheck glucose after approximately 15
minutes.
10. Which finding suggests increased intracranial pressure?
A. Hypotension
B. Decreased level of consciousness
C. Increased bowel sounds
D. Bradycardia without other findings
Answer: Decreased level of consciousness
Rationale: A change in level of consciousness is an early and important
indicator of neurological deterioration and increased intracranial
pressure.
Practice Exam 009 Questions
And Correct Answers (Verified
Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A nurse is assessing a client with hypovolemic shock. Which
finding requires immediate intervention?
A. Blood pressure 88/54 mm Hg
B. Urine output 20 mL/hr
C. Heart rate 124/min
D. Cool, clammy skin
Answer: Blood pressure 88/54 mm Hg
Rationale: Hypotension indicates inadequate tissue perfusion and is a
critical finding in hypovolemic shock requiring immediate treatment.
2. A client receiving digoxin has an apical pulse of 52/min. What
should the nurse do?
A. Administer the medication
B. Give the medication with food
C. Hold the medication
D. Recheck the pulse after administration
Answer: Hold the medication
,Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60/min and the provider
is notified.
3. Which assessment finding is most characteristic of left-sided heart
failure?
A. Peripheral edema
B. Jugular venous distention
C. Ascites
D. Crackles in the lungs
Answer: Crackles in the lungs
Rationale: Left-sided heart failure causes pulmonary congestion,
producing crackles, dyspnea, and orthopnea.
4. A nurse is teaching a client prescribed warfarin. Which statement
indicates correct understanding?
A. "I should avoid all foods containing vitamin K."
B. "I can take aspirin whenever I have a headache."
C. "I should keep my intake of vitamin K-containing foods consistent."
D. "I do not need blood tests while taking this medication."
Answer: "I should keep my intake of vitamin K-containing foods
consistent."
Rationale: Vitamin K affects warfarin activity. Clients should maintain a
consistent intake rather than completely avoiding vitamin K.
5. Which laboratory value should the nurse monitor for a client
receiving heparin therapy?
A. INR
B. Hemoglobin A1c
,C. aPTT
D. Serum sodium
Answer: aPTT
Rationale: Activated partial thromboplastin time is commonly used to
monitor unfractionated heparin therapy.
6. A client with chronic obstructive pulmonary disease is receiving
oxygen. Which prescription is most appropriate?
A. 15 L/min by nonrebreather mask
B. Low-flow oxygen as prescribed
C. Oxygen at maximum concentration continuously
D. Discontinue oxygen if respiratory rate increases
Answer: Low-flow oxygen as prescribed
Rationale: Clients with chronic obstructive pulmonary disease may
require carefully titrated oxygen to maintain adequate oxygenation.
7. Which finding is expected in a client experiencing diabetic
ketoacidosis?
A. Bradycardia
B. Kussmaul respirations
C. Severe hypoglycemia
D. Decreased serum ketones
Answer: Kussmaul respirations
Rationale: Kussmaul respirations are deep, rapid respirations that
compensate for metabolic acidosis in diabetic ketoacidosis.
8. A nurse is caring for a client with hypoglycemia. Which finding is
expected?
, A. Warm, dry skin
B. Fruity breath
C. Diaphoresis and tremors
D. Kussmaul respirations
Answer: Diaphoresis and tremors
Rationale: Adrenergic manifestations of hypoglycemia include sweating,
tremors, tachycardia, anxiety, and hunger.
9. A conscious client has a blood glucose level of 54 mg/dL. What
should the nurse provide?
A. Regular insulin
B. Approximately 15 g of rapid-acting carbohydrate
C. A high-protein meal only
D. Long-acting insulin
Answer: Approximately 15 g of rapid-acting carbohydrate
Rationale: The 15-15 approach is commonly used: provide about 15 g of
rapid carbohydrate and recheck glucose after approximately 15
minutes.
10. Which finding suggests increased intracranial pressure?
A. Hypotension
B. Decreased level of consciousness
C. Increased bowel sounds
D. Bradycardia without other findings
Answer: Decreased level of consciousness
Rationale: A change in level of consciousness is an early and important
indicator of neurological deterioration and increased intracranial
pressure.
