Newest 2026/2027 NCLEX-RN Exam – Master Review Practice Questions plus
rationales instant pdf
1. A nurse enters the room of a patient who is experiencing severe respiratory distress, has
a respiratory rate of 34/min, and has an oxygen saturation of 84%. What should the nurse
do first?
A. Obtain a complete health history
B. Assess the airway and initiate appropriate oxygenation support
C. Document the findings
D. Call the patient's family
Answer: B. Assess the airway and initiate appropriate oxygenation support
Rationale: Severe respiratory distress and hypoxemia represent an immediate threat to
breathing. Airway and breathing take priority over history, documentation, and nonurgent
communication.
2. A postoperative patient suddenly becomes restless, tachycardic, and hypotensive with
active bleeding from the surgical site. What is the priority nursing action?
A. Offer oral fluids
B. Address the hemorrhage and support circulation while obtaining emergency assistance
C. Encourage ambulation
D. Reassess the patient in 30 minutes
Answer: B. Address the hemorrhage and support circulation while obtaining emergency
assistance
Rationale: Active bleeding with hypotension and tachycardia suggests possible hemorrhagic
shock. Immediate intervention to control bleeding and support circulation is required.
3. A patient with diabetes is awake, sweating, trembling, and confused. The blood glucose is
48 mg/dL. What should the nurse do first?
A. Administer long-acting insulin
B. Give a rapid-acting source of glucose if the patient can safely swallow
C. Restrict oral intake
D. Administer potassium
Answer: B. Give a rapid-acting source of glucose if the patient can safely swallow
,Rationale: The patient has symptomatic hypoglycemia. A conscious patient who can swallow
safely should receive a rapid source of glucose followed by reassessment.
4. A patient receiving insulin becomes unconscious. What is the priority nursing action?
A. Give juice orally
B. Protect the airway and administer appropriate emergency treatment for severe
hypoglycemia
C. Encourage the patient to walk
D. Give additional insulin
Answer: B. Protect the airway and administer appropriate emergency treatment for severe
hypoglycemia
Rationale: An unconscious patient cannot safely receive oral fluids because of aspiration risk.
Airway protection and rapid treatment of severe hypoglycemia are priorities.
5. A patient receiving IV potassium chloride reports burning at the IV site. What should
the nurse do?
A. Increase the infusion rate
B. Assess the IV site and stop or pause the infusion according to protocol if infiltration or
irritation is suspected
C. Administer potassium by IV push
D. Ignore the complaint
Answer: B. Assess the IV site and stop or pause the infusion according to protocol if
infiltration or irritation is suspected
Rationale: IV potassium is irritating to tissue and requires careful administration. Potassium
chloride must never be administered by IV push.
6. A patient taking warfarin has an INR significantly above the therapeutic range and
reports black, tarry stools. What is the priority concern?
A. Constipation
B. Significant bleeding related to excessive anticoagulation
C. Dehydration only
D. Hyperglycemia
,Answer: B. Significant bleeding related to excessive anticoagulation
Rationale: Melena may indicate gastrointestinal bleeding. An elevated INR increases bleeding
risk and requires prompt assessment and appropriate intervention.
7. A patient receiving heparin develops bleeding from the gums and multiple new bruises.
What should the nurse assess first?
A. Appetite
B. Bleeding severity, vital signs, laboratory results, and medication administration
C. Sleep pattern
D. Skin temperature only
Answer: B. Bleeding severity, vital signs, laboratory results, and medication administration
Rationale: Active bleeding in a patient receiving anticoagulation requires immediate assessment
for severity and hemodynamic compromise.
8. A patient develops sudden facial drooping, right-sided weakness, and difficulty speaking.
What should the nurse do?
A. Allow the patient to sleep
B. Activate the appropriate stroke response and determine the last known well time
C. Give oral food
D. Wait for symptoms to resolve
Answer: B. Activate the appropriate stroke response and determine the last known well
time
Rationale: Sudden neurologic deficits are consistent with possible acute stroke. Rapid evaluation
is essential because treatment options are time-dependent.
9. A patient begins having a generalized tonic-clonic seizure. What is the priority nursing
action?
A. Restrain the patient's arms
B. Place a spoon in the patient's mouth
C. Protect the patient from injury and maintain airway safety
D. Give oral medication
, Answer: C. Protect the patient from injury and maintain airway safety
Rationale: During a seizure, the nurse should protect the patient from injury and maintain
airway safety. The patient should not be restrained and nothing should be placed in the mouth.
10. A patient has a seizure that has ended. What should the nurse assess first?
A. Dietary preferences
B. Airway, breathing, oxygenation, and level of consciousness
C. Family history
D. Long-term exercise habits
Answer: B. Airway, breathing, oxygenation, and level of consciousness
Rationale: The postictal period may be associated with impaired airway protection and altered
consciousness. Immediate assessment focuses on physiologic stability.
11. A patient with heart failure reports a 4-lb weight gain over 2 days and increasing
shortness of breath. What should the nurse recognize?
A. Expected recovery
B. Possible fluid retention and worsening heart failure
C. Improved cardiac function
D. Normal aging
Answer: B. Possible fluid retention and worsening heart failure
Rationale: Rapid weight gain commonly reflects fluid retention. Increasing dyspnea may indicate
worsening heart failure and requires prompt assessment.
12. A patient with left-sided heart failure develops severe dyspnea, crackles, and pink,
frothy sputum. What complication should the nurse suspect?
A. Constipation
B. Acute pulmonary edema
C. Hypoglycemia
D. Appendicitis
Answer: B. Acute pulmonary edema
rationales instant pdf
1. A nurse enters the room of a patient who is experiencing severe respiratory distress, has
a respiratory rate of 34/min, and has an oxygen saturation of 84%. What should the nurse
do first?
A. Obtain a complete health history
B. Assess the airway and initiate appropriate oxygenation support
C. Document the findings
D. Call the patient's family
Answer: B. Assess the airway and initiate appropriate oxygenation support
Rationale: Severe respiratory distress and hypoxemia represent an immediate threat to
breathing. Airway and breathing take priority over history, documentation, and nonurgent
communication.
2. A postoperative patient suddenly becomes restless, tachycardic, and hypotensive with
active bleeding from the surgical site. What is the priority nursing action?
A. Offer oral fluids
B. Address the hemorrhage and support circulation while obtaining emergency assistance
C. Encourage ambulation
D. Reassess the patient in 30 minutes
Answer: B. Address the hemorrhage and support circulation while obtaining emergency
assistance
Rationale: Active bleeding with hypotension and tachycardia suggests possible hemorrhagic
shock. Immediate intervention to control bleeding and support circulation is required.
3. A patient with diabetes is awake, sweating, trembling, and confused. The blood glucose is
48 mg/dL. What should the nurse do first?
A. Administer long-acting insulin
B. Give a rapid-acting source of glucose if the patient can safely swallow
C. Restrict oral intake
D. Administer potassium
Answer: B. Give a rapid-acting source of glucose if the patient can safely swallow
,Rationale: The patient has symptomatic hypoglycemia. A conscious patient who can swallow
safely should receive a rapid source of glucose followed by reassessment.
4. A patient receiving insulin becomes unconscious. What is the priority nursing action?
A. Give juice orally
B. Protect the airway and administer appropriate emergency treatment for severe
hypoglycemia
C. Encourage the patient to walk
D. Give additional insulin
Answer: B. Protect the airway and administer appropriate emergency treatment for severe
hypoglycemia
Rationale: An unconscious patient cannot safely receive oral fluids because of aspiration risk.
Airway protection and rapid treatment of severe hypoglycemia are priorities.
5. A patient receiving IV potassium chloride reports burning at the IV site. What should
the nurse do?
A. Increase the infusion rate
B. Assess the IV site and stop or pause the infusion according to protocol if infiltration or
irritation is suspected
C. Administer potassium by IV push
D. Ignore the complaint
Answer: B. Assess the IV site and stop or pause the infusion according to protocol if
infiltration or irritation is suspected
Rationale: IV potassium is irritating to tissue and requires careful administration. Potassium
chloride must never be administered by IV push.
6. A patient taking warfarin has an INR significantly above the therapeutic range and
reports black, tarry stools. What is the priority concern?
A. Constipation
B. Significant bleeding related to excessive anticoagulation
C. Dehydration only
D. Hyperglycemia
,Answer: B. Significant bleeding related to excessive anticoagulation
Rationale: Melena may indicate gastrointestinal bleeding. An elevated INR increases bleeding
risk and requires prompt assessment and appropriate intervention.
7. A patient receiving heparin develops bleeding from the gums and multiple new bruises.
What should the nurse assess first?
A. Appetite
B. Bleeding severity, vital signs, laboratory results, and medication administration
C. Sleep pattern
D. Skin temperature only
Answer: B. Bleeding severity, vital signs, laboratory results, and medication administration
Rationale: Active bleeding in a patient receiving anticoagulation requires immediate assessment
for severity and hemodynamic compromise.
8. A patient develops sudden facial drooping, right-sided weakness, and difficulty speaking.
What should the nurse do?
A. Allow the patient to sleep
B. Activate the appropriate stroke response and determine the last known well time
C. Give oral food
D. Wait for symptoms to resolve
Answer: B. Activate the appropriate stroke response and determine the last known well
time
Rationale: Sudden neurologic deficits are consistent with possible acute stroke. Rapid evaluation
is essential because treatment options are time-dependent.
9. A patient begins having a generalized tonic-clonic seizure. What is the priority nursing
action?
A. Restrain the patient's arms
B. Place a spoon in the patient's mouth
C. Protect the patient from injury and maintain airway safety
D. Give oral medication
, Answer: C. Protect the patient from injury and maintain airway safety
Rationale: During a seizure, the nurse should protect the patient from injury and maintain
airway safety. The patient should not be restrained and nothing should be placed in the mouth.
10. A patient has a seizure that has ended. What should the nurse assess first?
A. Dietary preferences
B. Airway, breathing, oxygenation, and level of consciousness
C. Family history
D. Long-term exercise habits
Answer: B. Airway, breathing, oxygenation, and level of consciousness
Rationale: The postictal period may be associated with impaired airway protection and altered
consciousness. Immediate assessment focuses on physiologic stability.
11. A patient with heart failure reports a 4-lb weight gain over 2 days and increasing
shortness of breath. What should the nurse recognize?
A. Expected recovery
B. Possible fluid retention and worsening heart failure
C. Improved cardiac function
D. Normal aging
Answer: B. Possible fluid retention and worsening heart failure
Rationale: Rapid weight gain commonly reflects fluid retention. Increasing dyspnea may indicate
worsening heart failure and requires prompt assessment.
12. A patient with left-sided heart failure develops severe dyspnea, crackles, and pink,
frothy sputum. What complication should the nurse suspect?
A. Constipation
B. Acute pulmonary edema
C. Hypoglycemia
D. Appendicitis
Answer: B. Acute pulmonary edema
