NCLEX-RN Comprehensive Practice
Exam 003 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client who has heart failure and is receiving
furosemide. Which finding should the nurse report immediately?
A. Blood pressure of 108/68 mm Hg
B. Urine output of 1,200 mL over 24 hours
C. Potassium level of 2.8 mEq/L
D. Weight loss of 1 kg in 24 hours
Answer: C. Potassium level of 2.8 mEq/L
Rationale: A potassium level below 3.5 mEq/L indicates hypokalemia.
Furosemide can cause potassium loss, and severe hypokalemia increases the
risk of dangerous cardiac dysrhythmias.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which prescription should the nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Encourage pursed-lip breathing
C. Oxygen at 10 L/min by nonrebreather mask continuously
D. Monitor oxygen saturation
Answer: C. Oxygen at 10 L/min by nonrebreather mask continuously
Rationale: Clients with COPD generally require carefully titrated oxygen.
Excessive oxygen administration can worsen carbon dioxide retention in some
clients.
,3. A nurse is assessing a client with suspected hypoglycemia. Which finding is
most expected?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and tremors
D. Kussmaul respirations
Answer: C. Diaphoresis and tremors
Rationale: Hypoglycemia activates the sympathetic nervous system,
producing sweating, tremors, palpitations, anxiety, and hunger.
4. A client receiving digoxin has an apical pulse of 54/min. What should the
nurse do?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Administer the medication with food
D. Recheck the pulse after exercise
Answer: B. Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60/min, and the provider
should be notified.
5. A nurse is caring for a client who has a new prescription for warfarin. Which
laboratory test is used to monitor therapy?
A. aPTT
B. INR
C. Platelet count
D. Serum creatinine
Answer: B. INR
,Rationale: Warfarin therapy is monitored using the international normalized
ratio (INR), which evaluates the effectiveness of anticoagulation.
6. A postoperative client suddenly develops dyspnea, chest pain, and
tachycardia. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Fluid overload
Answer: B. Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia
are classic findings of pulmonary embolism, which can occur after surgery
because of venous thromboembolism.
7. Which intervention is appropriate for a client experiencing an acute asthma
exacerbation?
A. Encourage rapid deep breathing
B. Administer the prescribed short-acting bronchodilator
C. Place the client flat in bed
D. Restrict fluids
Answer: B. Administer the prescribed short-acting bronchodilator
Rationale: Short-acting beta2 agonists such as albuterol provide rapid
bronchodilation during an acute asthma exacerbation.
8. A client with diabetes mellitus is unconscious and has a blood glucose level
of 38 mg/dL. Which intervention is priority?
A. Give oral juice
B. Administer IV dextrose as prescribed
C. Administer long-acting insulin
D. Encourage the client to eat a meal
, Answer: B. Administer IV dextrose as prescribed
Rationale: An unconscious client cannot safely swallow. Severe hypoglycemia
requires rapid administration of IV dextrose or glucagon when IV access is
unavailable.
9. A client with a head injury has a Glasgow Coma Scale score that decreases
from 13 to 9. What is the nurse's priority action?
A. Allow the client to sleep
B. Notify the provider immediately
C. Give oral fluids
D. Reassess in 4 hours
Answer: B. Notify the provider immediately
Rationale: A decreasing level of consciousness indicates possible neurologic
deterioration and increased intracranial pressure. Immediate evaluation is
required.
10. A nurse is teaching a client about nitroglycerin for angina. Which statement
indicates correct understanding?
A. "I should swallow the tablet whole."
B. "I should take the medication only after the pain becomes severe."
C. "I should sit down before taking the medication."
D. "I can store the tablets in my weekly pill organizer."
Answer: C. "I should sit down before taking the medication."
Rationale: Nitroglycerin can cause hypotension and dizziness. Sitting or lying
down reduces the risk of injury from a sudden drop in blood pressure.
11. A client is receiving a blood transfusion and develops chills, fever, and low
back pain. What is the nurse's priority action?
Exam 003 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client who has heart failure and is receiving
furosemide. Which finding should the nurse report immediately?
A. Blood pressure of 108/68 mm Hg
B. Urine output of 1,200 mL over 24 hours
C. Potassium level of 2.8 mEq/L
D. Weight loss of 1 kg in 24 hours
Answer: C. Potassium level of 2.8 mEq/L
Rationale: A potassium level below 3.5 mEq/L indicates hypokalemia.
Furosemide can cause potassium loss, and severe hypokalemia increases the
risk of dangerous cardiac dysrhythmias.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which prescription should the nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Encourage pursed-lip breathing
C. Oxygen at 10 L/min by nonrebreather mask continuously
D. Monitor oxygen saturation
Answer: C. Oxygen at 10 L/min by nonrebreather mask continuously
Rationale: Clients with COPD generally require carefully titrated oxygen.
Excessive oxygen administration can worsen carbon dioxide retention in some
clients.
,3. A nurse is assessing a client with suspected hypoglycemia. Which finding is
most expected?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and tremors
D. Kussmaul respirations
Answer: C. Diaphoresis and tremors
Rationale: Hypoglycemia activates the sympathetic nervous system,
producing sweating, tremors, palpitations, anxiety, and hunger.
4. A client receiving digoxin has an apical pulse of 54/min. What should the
nurse do?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Administer the medication with food
D. Recheck the pulse after exercise
Answer: B. Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60/min, and the provider
should be notified.
5. A nurse is caring for a client who has a new prescription for warfarin. Which
laboratory test is used to monitor therapy?
A. aPTT
B. INR
C. Platelet count
D. Serum creatinine
Answer: B. INR
,Rationale: Warfarin therapy is monitored using the international normalized
ratio (INR), which evaluates the effectiveness of anticoagulation.
6. A postoperative client suddenly develops dyspnea, chest pain, and
tachycardia. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Fluid overload
Answer: B. Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia
are classic findings of pulmonary embolism, which can occur after surgery
because of venous thromboembolism.
7. Which intervention is appropriate for a client experiencing an acute asthma
exacerbation?
A. Encourage rapid deep breathing
B. Administer the prescribed short-acting bronchodilator
C. Place the client flat in bed
D. Restrict fluids
Answer: B. Administer the prescribed short-acting bronchodilator
Rationale: Short-acting beta2 agonists such as albuterol provide rapid
bronchodilation during an acute asthma exacerbation.
8. A client with diabetes mellitus is unconscious and has a blood glucose level
of 38 mg/dL. Which intervention is priority?
A. Give oral juice
B. Administer IV dextrose as prescribed
C. Administer long-acting insulin
D. Encourage the client to eat a meal
, Answer: B. Administer IV dextrose as prescribed
Rationale: An unconscious client cannot safely swallow. Severe hypoglycemia
requires rapid administration of IV dextrose or glucagon when IV access is
unavailable.
9. A client with a head injury has a Glasgow Coma Scale score that decreases
from 13 to 9. What is the nurse's priority action?
A. Allow the client to sleep
B. Notify the provider immediately
C. Give oral fluids
D. Reassess in 4 hours
Answer: B. Notify the provider immediately
Rationale: A decreasing level of consciousness indicates possible neurologic
deterioration and increased intracranial pressure. Immediate evaluation is
required.
10. A nurse is teaching a client about nitroglycerin for angina. Which statement
indicates correct understanding?
A. "I should swallow the tablet whole."
B. "I should take the medication only after the pain becomes severe."
C. "I should sit down before taking the medication."
D. "I can store the tablets in my weekly pill organizer."
Answer: C. "I should sit down before taking the medication."
Rationale: Nitroglycerin can cause hypotension and dizziness. Sitting or lying
down reduces the risk of injury from a sudden drop in blood pressure.
11. A client is receiving a blood transfusion and develops chills, fever, and low
back pain. What is the nurse's priority action?
