NCLEX RN Next Generation Case Study
Exam 5 100 Questions And Correct
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Rationales 2026 Q&A Instant
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Case Study 1: Acute Heart Failure
A 72-year-old client with a history of hypertension and coronary artery disease
presents to the emergency department with increasing shortness of breath for
2 days. The client reports sleeping in a recliner because lying flat worsens
breathing. Assessment: BP 168/94 mm Hg, HR 108/min, RR 30/min, SpO₂ 86%
on room air. Crackles are heard bilaterally. The client has 3+ bilateral lower-
extremity edema.
Question 1
Which assessment finding requires the nurse's immediate attention?
A. 3+ bilateral lower-extremity edema
B. Blood pressure of 168/94 mm Hg
C. Oxygen saturation of 86% on room air
D. Difficulty sleeping flat
Answer: Oxygen saturation of 86% on room air
Rationale: Severe hypoxemia is the immediate threat to life. Airway and
breathing take priority over fluid retention, hypertension, and orthopnea.
Question 2
Which position should the nurse place the client in initially?
,A. Supine
B. High-Fowler's position
C. Trendelenburg position
D. Prone position
Answer: High-Fowler's position
Rationale: High-Fowler's positioning promotes lung expansion and decreases
venous return, which can improve oxygenation and reduce cardiac workload
in acute heart failure.
Question 3
Which prescription should the nurse implement first?
A. Administer IV loop diuretic
B. Obtain a daily weight
C. Restrict oral fluids
D. Teach a low-sodium diet
Answer: Administer supplemental oxygen
Rationale: The client's SpO₂ of 86% indicates significant hypoxemia.
Oxygenation should be addressed immediately before longer-term
interventions.
Question 4
The provider prescribes IV furosemide. Which finding should the nurse monitor
most closely after administration?
A. Serum potassium
B. Hemoglobin
C. Platelet count
D. Serum calcium
Answer: Serum potassium
Rationale: Furosemide can cause significant potassium loss, increasing the
risk for dysrhythmias.
Question 5
,Which findings indicate worsening pulmonary congestion? Select all that apply.
A. Increasing crackles
B. Pink, frothy sputum
C. Decreasing respiratory rate to 18/min
D. Increasing oxygen requirement
E. New severe dyspnea
Answer: Increasing crackles; Pink, frothy sputum; Increasing oxygen
requirement; New severe dyspnea
Rationale: Increasing crackles, frothy sputum, escalating oxygen needs, and
worsening dyspnea indicate increasing pulmonary edema.
Question 6
The client's condition improves after treatment. Which finding best indicates
effective therapy?
A. Urine output increases and respiratory distress decreases
B. Heart rate increases to 120/min
C. Crackles become more extensive
D. SpO₂ decreases to 82%
Answer: Urine output increases and respiratory distress decreases
Rationale: Increased diuresis reduces fluid overload, while improved
respiratory status indicates decreased pulmonary congestion.
Question 7
Which discharge instruction is most important for preventing recurrent fluid
overload?
A. Increase sodium intake when appetite is poor
B. Weigh daily at the same time
C. Drink unlimited fluids
D. Stop medications when symptoms improve
Answer: Weigh daily at the same time
Rationale: Daily weight detects fluid retention early. A rapid weight increase
should be reported according to the client's heart-failure plan.
, Question 8
Which client statement demonstrates correct understanding of heart-failure
management?
A. "I will stop my medication when my swelling goes away."
B. "I should report a rapid increase in my weight."
C. "I should add salt to meals if I feel weak."
D. "I only need to monitor my weight when I feel short of breath."
Answer: "I should report a rapid increase in my weight."
Rationale: Rapid weight gain can indicate fluid retention and worsening
heart failure. Medications and monitoring should continue even when
symptoms improve.
Case Study 2: Diabetic Ketoacidosis
A 24-year-old client with type 1 diabetes is admitted with nausea, vomiting,
abdominal pain, and excessive thirst. The client reports missing insulin doses
because of a recent respiratory infection. Assessment: BP 92/58 mm Hg, HR
124/min, RR 32/min with deep respirations, dry mucous membranes. Blood
glucose is 548 mg/dL.
Question 9
Which finding is most characteristic of diabetic ketoacidosis?
A. Bradycardia
B. Kussmaul respirations
C. Hypothermia
D. Increased urine concentration
Answer: Kussmaul respirations
Rationale: Deep, rapid Kussmaul respirations are a compensatory response to
metabolic acidosis caused by ketone accumulation.
Question 10
Which laboratory result would the nurse expect?
Exam 5 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
Case Study 1: Acute Heart Failure
A 72-year-old client with a history of hypertension and coronary artery disease
presents to the emergency department with increasing shortness of breath for
2 days. The client reports sleeping in a recliner because lying flat worsens
breathing. Assessment: BP 168/94 mm Hg, HR 108/min, RR 30/min, SpO₂ 86%
on room air. Crackles are heard bilaterally. The client has 3+ bilateral lower-
extremity edema.
Question 1
Which assessment finding requires the nurse's immediate attention?
A. 3+ bilateral lower-extremity edema
B. Blood pressure of 168/94 mm Hg
C. Oxygen saturation of 86% on room air
D. Difficulty sleeping flat
Answer: Oxygen saturation of 86% on room air
Rationale: Severe hypoxemia is the immediate threat to life. Airway and
breathing take priority over fluid retention, hypertension, and orthopnea.
Question 2
Which position should the nurse place the client in initially?
,A. Supine
B. High-Fowler's position
C. Trendelenburg position
D. Prone position
Answer: High-Fowler's position
Rationale: High-Fowler's positioning promotes lung expansion and decreases
venous return, which can improve oxygenation and reduce cardiac workload
in acute heart failure.
Question 3
Which prescription should the nurse implement first?
A. Administer IV loop diuretic
B. Obtain a daily weight
C. Restrict oral fluids
D. Teach a low-sodium diet
Answer: Administer supplemental oxygen
Rationale: The client's SpO₂ of 86% indicates significant hypoxemia.
Oxygenation should be addressed immediately before longer-term
interventions.
Question 4
The provider prescribes IV furosemide. Which finding should the nurse monitor
most closely after administration?
A. Serum potassium
B. Hemoglobin
C. Platelet count
D. Serum calcium
Answer: Serum potassium
Rationale: Furosemide can cause significant potassium loss, increasing the
risk for dysrhythmias.
Question 5
,Which findings indicate worsening pulmonary congestion? Select all that apply.
A. Increasing crackles
B. Pink, frothy sputum
C. Decreasing respiratory rate to 18/min
D. Increasing oxygen requirement
E. New severe dyspnea
Answer: Increasing crackles; Pink, frothy sputum; Increasing oxygen
requirement; New severe dyspnea
Rationale: Increasing crackles, frothy sputum, escalating oxygen needs, and
worsening dyspnea indicate increasing pulmonary edema.
Question 6
The client's condition improves after treatment. Which finding best indicates
effective therapy?
A. Urine output increases and respiratory distress decreases
B. Heart rate increases to 120/min
C. Crackles become more extensive
D. SpO₂ decreases to 82%
Answer: Urine output increases and respiratory distress decreases
Rationale: Increased diuresis reduces fluid overload, while improved
respiratory status indicates decreased pulmonary congestion.
Question 7
Which discharge instruction is most important for preventing recurrent fluid
overload?
A. Increase sodium intake when appetite is poor
B. Weigh daily at the same time
C. Drink unlimited fluids
D. Stop medications when symptoms improve
Answer: Weigh daily at the same time
Rationale: Daily weight detects fluid retention early. A rapid weight increase
should be reported according to the client's heart-failure plan.
, Question 8
Which client statement demonstrates correct understanding of heart-failure
management?
A. "I will stop my medication when my swelling goes away."
B. "I should report a rapid increase in my weight."
C. "I should add salt to meals if I feel weak."
D. "I only need to monitor my weight when I feel short of breath."
Answer: "I should report a rapid increase in my weight."
Rationale: Rapid weight gain can indicate fluid retention and worsening
heart failure. Medications and monitoring should continue even when
symptoms improve.
Case Study 2: Diabetic Ketoacidosis
A 24-year-old client with type 1 diabetes is admitted with nausea, vomiting,
abdominal pain, and excessive thirst. The client reports missing insulin doses
because of a recent respiratory infection. Assessment: BP 92/58 mm Hg, HR
124/min, RR 32/min with deep respirations, dry mucous membranes. Blood
glucose is 548 mg/dL.
Question 9
Which finding is most characteristic of diabetic ketoacidosis?
A. Bradycardia
B. Kussmaul respirations
C. Hypothermia
D. Increased urine concentration
Answer: Kussmaul respirations
Rationale: Deep, rapid Kussmaul respirations are a compensatory response to
metabolic acidosis caused by ketone accumulation.
Question 10
Which laboratory result would the nurse expect?
