Florida NCLEX-PN EXAM PRACTICE TEST
QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES | INSTANT
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1. A nurse is caring for a patient with congestive heart failure. Which of the following
assessments is most important to monitor daily?
A. Bowel sounds
B. Weight
C. Temperature
D. Pupillary response
Answer: B. Weight
Rationale: Daily weight monitoring is crucial for detecting fluid retention in patients with
congestive heart failure.
2. Which of the following is a common side effect of loop diuretics?
A. Hyperkalemia
B. Hypokalemia
C. Hypertension
D. Bradycardia
Answer: B. Hypokalemia
Rationale: Loop diuretics increase potassium excretion, which may lead to hypokalemia.
3. A patient with diabetes mellitus has a blood glucose of 320 mg/dL. What is the nurse’s
priority action?
A. Administer insulin per sliding scale
B. Provide orange juice
C. Notify the provider immediately
D. Encourage exercise
,Answer: A. Administer insulin per sliding scale
Rationale: Hyperglycemia above normal requires prompt correction with insulin to prevent
complications such as diabetic ketoacidosis.
4. Which of the following is the earliest sign of hypoxia in a patient?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Hypotension
Answer: B. Restlessness
Rationale: Restlessness is an early sign of hypoxia due to inadequate oxygen delivery to tissues.
5. A patient with COPD is receiving oxygen at 2 L/min via nasal cannula. The nurse notes
increasing confusion. What should the nurse do first?
A. Increase oxygen to 4 L/min
B. Assess oxygen saturation
C. Notify the provider immediately
D. Encourage deep breathing
Answer: B. Assess oxygen saturation
Rationale: Confusion can indicate hypoxia or hypercapnia; the nurse should first assess oxygen
levels before intervening.
6. Which nursing intervention helps prevent deep vein thrombosis in postoperative patients?
A. Strict bed rest
B. Early ambulation
C. Administering analgesics
D. Applying heating pads
Answer: B. Early ambulation
Rationale: Early mobilization promotes circulation and prevents venous stasis, reducing DVT risk.
7. A patient is receiving morphine for pain. Which of the following should the nurse monitor
closely?
A. Blood pressure
, B. Respiratory rate
C. Heart rate
D. Temperature
Answer: B. Respiratory rate
Rationale: Morphine can cause respiratory depression; monitoring rate is essential to patient
safety.
8. Which of the following findings would indicate fluid overload?
A. Dry mucous membranes
B. Peripheral edema
C. Sunken eyes
D. Hypotension
Answer: B. Peripheral edema
Rationale: Peripheral edema is a common sign of excess fluid accumulation in the body.
9. Which lab value should the nurse monitor for a patient receiving heparin therapy?
A. INR
B. aPTT
C. Platelet count
D. Hemoglobin
Answer: B. aPTT
Rationale: Heparin affects the intrinsic pathway of coagulation; aPTT is used to monitor
therapeutic levels.
10. A patient with a nasogastric tube has sudden respiratory distress. What is the nurse’s first
action?
A. Irrigate the tube
B. Assess lung sounds
C. Remove the tube
D. Call the provider
Answer: B. Assess lung sounds
Rationale: Respiratory distress could indicate misplacement or aspiration; assessment guides the
immediate intervention.
QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES | INSTANT
DOWNLOAD PDF
1. A nurse is caring for a patient with congestive heart failure. Which of the following
assessments is most important to monitor daily?
A. Bowel sounds
B. Weight
C. Temperature
D. Pupillary response
Answer: B. Weight
Rationale: Daily weight monitoring is crucial for detecting fluid retention in patients with
congestive heart failure.
2. Which of the following is a common side effect of loop diuretics?
A. Hyperkalemia
B. Hypokalemia
C. Hypertension
D. Bradycardia
Answer: B. Hypokalemia
Rationale: Loop diuretics increase potassium excretion, which may lead to hypokalemia.
3. A patient with diabetes mellitus has a blood glucose of 320 mg/dL. What is the nurse’s
priority action?
A. Administer insulin per sliding scale
B. Provide orange juice
C. Notify the provider immediately
D. Encourage exercise
,Answer: A. Administer insulin per sliding scale
Rationale: Hyperglycemia above normal requires prompt correction with insulin to prevent
complications such as diabetic ketoacidosis.
4. Which of the following is the earliest sign of hypoxia in a patient?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Hypotension
Answer: B. Restlessness
Rationale: Restlessness is an early sign of hypoxia due to inadequate oxygen delivery to tissues.
5. A patient with COPD is receiving oxygen at 2 L/min via nasal cannula. The nurse notes
increasing confusion. What should the nurse do first?
A. Increase oxygen to 4 L/min
B. Assess oxygen saturation
C. Notify the provider immediately
D. Encourage deep breathing
Answer: B. Assess oxygen saturation
Rationale: Confusion can indicate hypoxia or hypercapnia; the nurse should first assess oxygen
levels before intervening.
6. Which nursing intervention helps prevent deep vein thrombosis in postoperative patients?
A. Strict bed rest
B. Early ambulation
C. Administering analgesics
D. Applying heating pads
Answer: B. Early ambulation
Rationale: Early mobilization promotes circulation and prevents venous stasis, reducing DVT risk.
7. A patient is receiving morphine for pain. Which of the following should the nurse monitor
closely?
A. Blood pressure
, B. Respiratory rate
C. Heart rate
D. Temperature
Answer: B. Respiratory rate
Rationale: Morphine can cause respiratory depression; monitoring rate is essential to patient
safety.
8. Which of the following findings would indicate fluid overload?
A. Dry mucous membranes
B. Peripheral edema
C. Sunken eyes
D. Hypotension
Answer: B. Peripheral edema
Rationale: Peripheral edema is a common sign of excess fluid accumulation in the body.
9. Which lab value should the nurse monitor for a patient receiving heparin therapy?
A. INR
B. aPTT
C. Platelet count
D. Hemoglobin
Answer: B. aPTT
Rationale: Heparin affects the intrinsic pathway of coagulation; aPTT is used to monitor
therapeutic levels.
10. A patient with a nasogastric tube has sudden respiratory distress. What is the nurse’s first
action?
A. Irrigate the tube
B. Assess lung sounds
C. Remove the tube
D. Call the provider
Answer: B. Assess lung sounds
Rationale: Respiratory distress could indicate misplacement or aspiration; assessment guides the
immediate intervention.
