NCLEX-RN Comprehensive Practice
Exam 010 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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Question 1
A nurse is assessing a client who has hypovolemic shock. Which finding
requires the nurse’s immediate attention?
A. Heart rate of 112/min
B. Blood pressure of 88/54 mm Hg
C. Urine output of 15 mL/hr
D. Respiratory rate of 24/min
Answer: C. Urine output of 15 mL/hr
Rationale: Urine output below 30 mL/hr indicates inadequate renal perfusion
and worsening shock. This finding requires immediate intervention to prevent
acute kidney injury and further organ dysfunction.
Question 2
A client with heart failure reports increasing shortness of breath and suddenly
becomes restless. Which action should the nurse take first?
A. Obtain the client's weight
B. Place the client in high-Fowler's position
C. Encourage oral fluids
D. Administer a prescribed sedative
Answer: B. Place the client in high-Fowler's position
,Rationale: High-Fowler's positioning improves lung expansion and decreases
venous return, helping reduce pulmonary congestion and improve
oxygenation.
Question 3
A client receiving digoxin has an apical pulse of 52/min. What should the nurse
do?
A. Administer the medication as prescribed
B. Give the medication with food
C. Hold the medication and notify the provider
D. Recheck the pulse after ambulation
Answer: C. Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. An apical pulse below 60/min in an
adult is generally a reason to withhold digoxin and notify the provider.
Question 4
A client with diabetes mellitus is awake, sweating, and shaky. The blood
glucose level is 54 mg/dL. What should the nurse do first?
A. Administer regular insulin
B. Give 15 g of a rapid-acting carbohydrate
C. Administer glucagon intramuscularly
D. Encourage the client to exercise
Answer: B. Give 15 g of a rapid-acting carbohydrate
Rationale: A conscious client with hypoglycemia should receive
approximately 15 g of a rapidly absorbed carbohydrate, followed by
reassessment of glucose after about 15 minutes.
Question 5
A nurse is caring for a client receiving a blood transfusion. The client develops
chills, fever, and flank pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
,C. Administer acetaminophen
D. Obtain a urine specimen
Answer: B. Stop the transfusion
Rationale: Fever, chills, and flank pain may indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately, and the
IV should be maintained with appropriate compatible fluid using new tubing.
Question 6
A client with chronic obstructive pulmonary disease is receiving oxygen. Which
oxygen delivery method is most appropriate for controlled oxygen
administration?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise concentration of oxygen and is
useful when controlled oxygen therapy is needed, particularly for clients with
COPD.
Question 7
A client taking warfarin should be taught to report which finding immediately?
A. Mild fatigue
B. Increased appetite
C. Black, tarry stools
D. Occasional thirst
Answer: C. Black, tarry stools
Rationale: Black, tarry stools may indicate gastrointestinal bleeding, a serious
complication of anticoagulant therapy.
Question 8
, A nurse is caring for a client with increased intracranial pressure. Which
intervention is appropriate?
A. Keep the neck flexed
B. Place the client in Trendelenburg position
C. Elevate the head of the bed approximately 30 degrees
D. Encourage frequent coughing
Answer: C. Elevate the head of the bed approximately 30 degrees
Rationale: Elevating the head of the bed and maintaining neutral neck
alignment promotes venous drainage from the brain and can help reduce
intracranial pressure.
Question 9
A client with a new tracheostomy suddenly becomes restless and cyanotic.
What should the nurse do first?
A. Remove the tracheostomy tube
B. Assess the airway and oxygenation
C. Administer a sedative
D. Place the client supine
Answer: B. Assess the airway and oxygenation
Rationale: Restlessness and cyanosis indicate possible airway obstruction and
hypoxemia. Airway and breathing must be assessed immediately and
emergency interventions initiated as indicated.
Question 10
A nurse is teaching a client who has a new prescription for albuterol inhaler.
Which statement indicates correct understanding?
A. "I should use this medication to prevent all asthma attacks."
B. "This medication should help relieve acute bronchospasm."
C. "I should stop using my inhaled corticosteroid."
D. "I should expect my heart rate to decrease."
Answer: B. "This medication should help relieve acute bronchospasm."
Exam 010 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
Question 1
A nurse is assessing a client who has hypovolemic shock. Which finding
requires the nurse’s immediate attention?
A. Heart rate of 112/min
B. Blood pressure of 88/54 mm Hg
C. Urine output of 15 mL/hr
D. Respiratory rate of 24/min
Answer: C. Urine output of 15 mL/hr
Rationale: Urine output below 30 mL/hr indicates inadequate renal perfusion
and worsening shock. This finding requires immediate intervention to prevent
acute kidney injury and further organ dysfunction.
Question 2
A client with heart failure reports increasing shortness of breath and suddenly
becomes restless. Which action should the nurse take first?
A. Obtain the client's weight
B. Place the client in high-Fowler's position
C. Encourage oral fluids
D. Administer a prescribed sedative
Answer: B. Place the client in high-Fowler's position
,Rationale: High-Fowler's positioning improves lung expansion and decreases
venous return, helping reduce pulmonary congestion and improve
oxygenation.
Question 3
A client receiving digoxin has an apical pulse of 52/min. What should the nurse
do?
A. Administer the medication as prescribed
B. Give the medication with food
C. Hold the medication and notify the provider
D. Recheck the pulse after ambulation
Answer: C. Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. An apical pulse below 60/min in an
adult is generally a reason to withhold digoxin and notify the provider.
Question 4
A client with diabetes mellitus is awake, sweating, and shaky. The blood
glucose level is 54 mg/dL. What should the nurse do first?
A. Administer regular insulin
B. Give 15 g of a rapid-acting carbohydrate
C. Administer glucagon intramuscularly
D. Encourage the client to exercise
Answer: B. Give 15 g of a rapid-acting carbohydrate
Rationale: A conscious client with hypoglycemia should receive
approximately 15 g of a rapidly absorbed carbohydrate, followed by
reassessment of glucose after about 15 minutes.
Question 5
A nurse is caring for a client receiving a blood transfusion. The client develops
chills, fever, and flank pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
,C. Administer acetaminophen
D. Obtain a urine specimen
Answer: B. Stop the transfusion
Rationale: Fever, chills, and flank pain may indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately, and the
IV should be maintained with appropriate compatible fluid using new tubing.
Question 6
A client with chronic obstructive pulmonary disease is receiving oxygen. Which
oxygen delivery method is most appropriate for controlled oxygen
administration?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise concentration of oxygen and is
useful when controlled oxygen therapy is needed, particularly for clients with
COPD.
Question 7
A client taking warfarin should be taught to report which finding immediately?
A. Mild fatigue
B. Increased appetite
C. Black, tarry stools
D. Occasional thirst
Answer: C. Black, tarry stools
Rationale: Black, tarry stools may indicate gastrointestinal bleeding, a serious
complication of anticoagulant therapy.
Question 8
, A nurse is caring for a client with increased intracranial pressure. Which
intervention is appropriate?
A. Keep the neck flexed
B. Place the client in Trendelenburg position
C. Elevate the head of the bed approximately 30 degrees
D. Encourage frequent coughing
Answer: C. Elevate the head of the bed approximately 30 degrees
Rationale: Elevating the head of the bed and maintaining neutral neck
alignment promotes venous drainage from the brain and can help reduce
intracranial pressure.
Question 9
A client with a new tracheostomy suddenly becomes restless and cyanotic.
What should the nurse do first?
A. Remove the tracheostomy tube
B. Assess the airway and oxygenation
C. Administer a sedative
D. Place the client supine
Answer: B. Assess the airway and oxygenation
Rationale: Restlessness and cyanosis indicate possible airway obstruction and
hypoxemia. Airway and breathing must be assessed immediately and
emergency interventions initiated as indicated.
Question 10
A nurse is teaching a client who has a new prescription for albuterol inhaler.
Which statement indicates correct understanding?
A. "I should use this medication to prevent all asthma attacks."
B. "This medication should help relieve acute bronchospasm."
C. "I should stop using my inhaled corticosteroid."
D. "I should expect my heart rate to decrease."
Answer: B. "This medication should help relieve acute bronchospasm."
