NCLEX-RN
Exam Actual Questions & Answers
Guaranteed Pass| Latest Update
,1. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who has an oxygen saturation of 89% on room air. The
nurse should administer oxygen at a rate that maintains saturation
between which range?
A. 88-92%
B. 95-100%
C. 85-88%
D. 92-96%
Answer: A. 88-92%
Rationale: Clients with COPD rely on a hypoxic drive to stimulate breathing
because chronic CO2 retention blunts the normal hypercapnic drive.
Maintaining saturation at 88-92% prevents suppression of the respiratory
drive while still providing adequate oxygenation; over-oxygenating can cause
hypoventilation and worsening hypercapnia.
2. A client with a new diagnosis of heart failure is prescribed
furosemide. Which laboratory value requires immediate follow-up?
A. Sodium 138 mEq/L
B. Potassium 3.0 mEq/L
C. Calcium 9.5 mg/dL
D. Glucose 110 mg/dL
Answer: B. Potassium 3.0 mEq/L
Rationale: Furosemide is a loop diuretic that causes potassium wasting. A
potassium level of 3.0 mEq/L is below normal (3.5-5.0) and places the client
at risk for dangerous dysrhythmias, requiring prompt notification of the
provider and possible repletion.
,3. The nurse is assessing a client 24 hours after a total hip replacement.
Which finding requires immediate intervention?
A. Pain rated 4/10 at the incision
B. Sudden onset of shortness of breath and chest pain
C. Serosanguineous drainage on the dressing
D. Temperature of 100.1°F (37.8°C)
Answer: B. Sudden onset of shortness of breath and chest pain
Rationale: Sudden dyspnea and chest pain after orthopedic surgery are
classic signs of pulmonary embolism, a life-threatening complication
requiring immediate assessment, oxygen, and provider notification. The other
findings are expected postoperative occurrences.
4. A client with diabetic ketoacidosis (DKA) is receiving an IV insulin
infusion. Which finding indicates the treatment is effective?
A. Blood glucose decreasing by 200 mg/dL per hour
B. Serum potassium rising to 6.5 mEq/L
C. Anion gap closing toward normal
D. Urine output decreasing to 20 mL/hr
Answer: C. Anion gap closing toward normal
Rationale: The goal of DKA treatment is resolution of the metabolic acidosis,
reflected by a closing anion gap. Glucose should fall gradually (50-75
mg/dL/hr, not 200) to prevent cerebral edema, and potassium typically falls
with insulin therapy, requiring supplementation, not a rise to 6.5.
, 5. A nurse is caring for a client immediately after a thyroidectomy.
Which assessment finding is most concerning?
A. Hoarseness when speaking
B. Tingling around the mouth and fingers
C. Mild sore throat
D. Serosanguineous drainage of 5 mL on the dressing
Answer: B. Tingling around the mouth and fingers
Rationale: Perioral and finger tingling suggests hypocalcemia from
accidental parathyroid gland removal or injury during thyroidectomy, which
can progress to tetany and laryngospasm. This requires immediate calcium
level assessment and provider notification.
6. A client with cirrhosis develops asterixis and confusion. The nurse
anticipates the provider will prescribe which medication?
A. Spironolactone
B. Lactulose
C. Furosemide
D. Propranolol
Answer: B. Lactulose
Rationale: Asterixis and confusion in a client with cirrhosis indicate hepatic
encephalopathy, caused by elevated ammonia levels. Lactulose promotes
ammonia excretion through the stool, making it the priority intervention.
Exam Actual Questions & Answers
Guaranteed Pass| Latest Update
,1. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who has an oxygen saturation of 89% on room air. The
nurse should administer oxygen at a rate that maintains saturation
between which range?
A. 88-92%
B. 95-100%
C. 85-88%
D. 92-96%
Answer: A. 88-92%
Rationale: Clients with COPD rely on a hypoxic drive to stimulate breathing
because chronic CO2 retention blunts the normal hypercapnic drive.
Maintaining saturation at 88-92% prevents suppression of the respiratory
drive while still providing adequate oxygenation; over-oxygenating can cause
hypoventilation and worsening hypercapnia.
2. A client with a new diagnosis of heart failure is prescribed
furosemide. Which laboratory value requires immediate follow-up?
A. Sodium 138 mEq/L
B. Potassium 3.0 mEq/L
C. Calcium 9.5 mg/dL
D. Glucose 110 mg/dL
Answer: B. Potassium 3.0 mEq/L
Rationale: Furosemide is a loop diuretic that causes potassium wasting. A
potassium level of 3.0 mEq/L is below normal (3.5-5.0) and places the client
at risk for dangerous dysrhythmias, requiring prompt notification of the
provider and possible repletion.
,3. The nurse is assessing a client 24 hours after a total hip replacement.
Which finding requires immediate intervention?
A. Pain rated 4/10 at the incision
B. Sudden onset of shortness of breath and chest pain
C. Serosanguineous drainage on the dressing
D. Temperature of 100.1°F (37.8°C)
Answer: B. Sudden onset of shortness of breath and chest pain
Rationale: Sudden dyspnea and chest pain after orthopedic surgery are
classic signs of pulmonary embolism, a life-threatening complication
requiring immediate assessment, oxygen, and provider notification. The other
findings are expected postoperative occurrences.
4. A client with diabetic ketoacidosis (DKA) is receiving an IV insulin
infusion. Which finding indicates the treatment is effective?
A. Blood glucose decreasing by 200 mg/dL per hour
B. Serum potassium rising to 6.5 mEq/L
C. Anion gap closing toward normal
D. Urine output decreasing to 20 mL/hr
Answer: C. Anion gap closing toward normal
Rationale: The goal of DKA treatment is resolution of the metabolic acidosis,
reflected by a closing anion gap. Glucose should fall gradually (50-75
mg/dL/hr, not 200) to prevent cerebral edema, and potassium typically falls
with insulin therapy, requiring supplementation, not a rise to 6.5.
, 5. A nurse is caring for a client immediately after a thyroidectomy.
Which assessment finding is most concerning?
A. Hoarseness when speaking
B. Tingling around the mouth and fingers
C. Mild sore throat
D. Serosanguineous drainage of 5 mL on the dressing
Answer: B. Tingling around the mouth and fingers
Rationale: Perioral and finger tingling suggests hypocalcemia from
accidental parathyroid gland removal or injury during thyroidectomy, which
can progress to tetany and laryngospasm. This requires immediate calcium
level assessment and provider notification.
6. A client with cirrhosis develops asterixis and confusion. The nurse
anticipates the provider will prescribe which medication?
A. Spironolactone
B. Lactulose
C. Furosemide
D. Propranolol
Answer: B. Lactulose
Rationale: Asterixis and confusion in a client with cirrhosis indicate hepatic
encephalopathy, caused by elevated ammonia levels. Lactulose promotes
ammonia excretion through the stool, making it the priority intervention.
