NCLEX-RN Comprehensive Practice
Exam 2026
Medical-Surgical Nursing: Respiratory,
Cardiac & Critical Care
50 Questions with Detailed Rationales All
NCLEX-RN Client Needs Categories 2026
Edition
1|Page
, SECTION 1: RESPIRATORY MANAGEMENT
Question 1
A 68-year-old client with COPD is admitted with acute exacerbation. Assessment reveals: BP 142/88 mmHg, HR
104 bpm, RR 32 breaths/min, SpO2 84% on room air, pursed-lip breathing, use of accessory muscles, and barrel
chest. ABG results: pH 7.32, PaCO2 58 mmHg, HCO3- 32 mEq/L, PaO2 56 mmHg. Which oxygen delivery method
should the nurse initiate?
A) Non-rebreather mask at 15 L/min
B) Nasal cannula at 1-2 L/min
C) Venturi mask at 60% FiO2
D) BiPAP at 15/5 cmH2O
Correct answer: B
Explanation:
• COPD clients rely on hypoxic drive for respiratory stimulus — high-flow oxygen can suppress respiratory
drive and worsen CO2 retention
• Nasal cannula at 1-2 L/min provides low-flow, controlled oxygen delivery appropriate for COPD
exacerbation
• ABG shows chronic respiratory acidosis with metabolic compensation (elevated HCO3-), confirming chronic CO2
retention
• (A) Non-rebreather at 15 L/min delivers 80-100% FiO2 — dangerously high for a COPD client and may eliminate
hypoxic drive
• (C) Venturi mask at 60% is too high for a known CO2 retainer; Venturi masks are useful for precise delivery but
should start at 24-28% in COPD
• (D) BiPAP may be indicated if low-flow oxygen fails, but is not the first-line intervention — start
conservative and escalate
NCLEX Category: Physiological Integrity — Physiological Adaptation Cognitive Level:
Application
Question 2
A nurse is caring for a client 2 hours post-bronchoscopy. The client reports mild throat soreness and requests
water. Which action should the nurse take FIRST?
A) Provide ice chips for comfort
B) Assess the gag reflex before offering fluids
C) Administer prescribed throat lozenges
D) Offer clear liquids at room temperature
Correct answer: B
Explanation:
2|Page
, • Post-bronchoscopy, the throat is anesthetized with local anesthetic (lidocaine spray) — gag reflex may be
suppressed for 2-4 hours
• Aspiration risk is high if gag reflex has not returned — the nurse MUST verify gag reflex before any oral intake
• (A) Ice chips are oral intake — same aspiration risk applies if gag reflex is absent
• (C) Throat lozenges require swallowing — contraindicated without confirmed gag reflex
• (D) Clear liquids are appropriate AFTER gag reflex returns, not before assessment
NCLEX Category: Physiological Integrity — Reduction of Risk Potential Cognitive
Level: Application
Question 3
A client with pneumonia has the following ABG results: pH 7.29, PaCO2 52 mmHg, HCO3- 24 mEq/L, PaO2 62 mmHg.
The nurse interprets this as:
A) Respiratory acidosis, uncompensated
B) Metabolic acidosis, uncompensated
C) Respiratory acidosis with full metabolic compensation
D) Mixed respiratory and metabolic acidosis
Correct answer: A
Explanation:
• pH 7.29 → Acidotic (<7.35)
• PaCO2 52 → Elevated = respiratory cause (CO2 retention from impaired gas exchange)
• HCO3- 24 → Normal range (22-26) = kidneys have NOT begun compensating
• Conclusion: Respiratory acidosis, uncompensated — consistent with pneumonia impairing ventilation
• (B) Metabolic acidosis would show decreased HCO3- with normal PaCO2
• (C) Full compensation would show HCO3- elevated above normal range AND pH returning toward 7.35-7.45
• (D) Mixed acidosis would show both elevated PaCO2 AND decreased HCO3-
NCLEX Category: Physiological Integrity — Physiological Adaptation Cognitive Level:
Analysis
Question 4
A nurse is assessing a client with a chest tube connected to a water-seal drainage system. Which finding
requires IMMEDIATE intervention?
A) Continuous bubbling in the water-seal chamber
B) Tidaling (fluctuation) in the water-seal chamber during respiration
C) 50 mL of serosanguineous drainage in the collection chamber over 2 hours
D) The drainage system is positioned below the level of the chest
Correct answer: A
Explanation:
3|Page
, • Continuous bubbling in the water-seal chamber indicates an air leak in the system — this requires immediate
investigation
• Air leak sources: connection sites, tubing crack, or ongoing bronchopleural fistula — assess all
connections first, then notify provider
• (B) Tidaling is EXPECTED and indicates the system is patent — absence of tidaling may indicate lung re-expansion
or obstruction
• (C) 50 mL over 2 hours is within acceptable range — drainage >100 mL/hr is concerning and requires notification
• (D) Drainage system SHOULD be below chest level to facilitate gravity drainage — this is correct positioning
NCLEX Category: Physiological Integrity — Reduction of Risk Potential Cognitive
Level: Analysis
Question 5
A client is admitted with suspected tuberculosis (TB). Which combination of actions should the nurse
implement? (Select All That Apply)
A) Place client in a negative-pressure airborne isolation room
B) Wear an N95 respirator when entering the room
C) Obtain three sputum specimens for acid-fast bacilli (AFB) on consecutive mornings
D) Administer BCG vaccine to the client immediately
E) Initiate a 4-drug regimen: INH, rifampin, pyrazinamide, and ethambutol as ordered
F) Place a surgical mask on the client during transport
Correct answer: A, B, C, E, F
Explanation:
• (A) Negative-pressure airborne isolation is mandatory for suspected/confirmed TB — prevents airborne
Mycobacterium tuberculosis from escaping the room
• (B) N95 respirator (not surgical mask) is required for healthcare workers — TB particles are 1-5 microns,
requiring N95 filtration
• (C) Three consecutive morning sputum specimens are standard for AFB smear and culture — morning specimens
yield highest organism concentration
• (D) BCG vaccine is a PREVENTIVE vaccine used in endemic countries — it is NOT a treatment for active TB and is
not routinely given in the U.S.
• (E) Standard initial TB treatment is RIPE therapy (Rifampin, INH, Pyrazinamide, Ethambutol) for the intensive
phase
• (F) Surgical mask on the CLIENT during transport reduces droplet nuclei dispersal — protects others in the facility
NCLEX Category: Safe & Effective Care Environment — Safety & Infection Control Cognitive Level:
Application
SECTION 2: CARDIAC & VASCULAR MANAGEMENT
4|Page
Exam 2026
Medical-Surgical Nursing: Respiratory,
Cardiac & Critical Care
50 Questions with Detailed Rationales All
NCLEX-RN Client Needs Categories 2026
Edition
1|Page
, SECTION 1: RESPIRATORY MANAGEMENT
Question 1
A 68-year-old client with COPD is admitted with acute exacerbation. Assessment reveals: BP 142/88 mmHg, HR
104 bpm, RR 32 breaths/min, SpO2 84% on room air, pursed-lip breathing, use of accessory muscles, and barrel
chest. ABG results: pH 7.32, PaCO2 58 mmHg, HCO3- 32 mEq/L, PaO2 56 mmHg. Which oxygen delivery method
should the nurse initiate?
A) Non-rebreather mask at 15 L/min
B) Nasal cannula at 1-2 L/min
C) Venturi mask at 60% FiO2
D) BiPAP at 15/5 cmH2O
Correct answer: B
Explanation:
• COPD clients rely on hypoxic drive for respiratory stimulus — high-flow oxygen can suppress respiratory
drive and worsen CO2 retention
• Nasal cannula at 1-2 L/min provides low-flow, controlled oxygen delivery appropriate for COPD
exacerbation
• ABG shows chronic respiratory acidosis with metabolic compensation (elevated HCO3-), confirming chronic CO2
retention
• (A) Non-rebreather at 15 L/min delivers 80-100% FiO2 — dangerously high for a COPD client and may eliminate
hypoxic drive
• (C) Venturi mask at 60% is too high for a known CO2 retainer; Venturi masks are useful for precise delivery but
should start at 24-28% in COPD
• (D) BiPAP may be indicated if low-flow oxygen fails, but is not the first-line intervention — start
conservative and escalate
NCLEX Category: Physiological Integrity — Physiological Adaptation Cognitive Level:
Application
Question 2
A nurse is caring for a client 2 hours post-bronchoscopy. The client reports mild throat soreness and requests
water. Which action should the nurse take FIRST?
A) Provide ice chips for comfort
B) Assess the gag reflex before offering fluids
C) Administer prescribed throat lozenges
D) Offer clear liquids at room temperature
Correct answer: B
Explanation:
2|Page
, • Post-bronchoscopy, the throat is anesthetized with local anesthetic (lidocaine spray) — gag reflex may be
suppressed for 2-4 hours
• Aspiration risk is high if gag reflex has not returned — the nurse MUST verify gag reflex before any oral intake
• (A) Ice chips are oral intake — same aspiration risk applies if gag reflex is absent
• (C) Throat lozenges require swallowing — contraindicated without confirmed gag reflex
• (D) Clear liquids are appropriate AFTER gag reflex returns, not before assessment
NCLEX Category: Physiological Integrity — Reduction of Risk Potential Cognitive
Level: Application
Question 3
A client with pneumonia has the following ABG results: pH 7.29, PaCO2 52 mmHg, HCO3- 24 mEq/L, PaO2 62 mmHg.
The nurse interprets this as:
A) Respiratory acidosis, uncompensated
B) Metabolic acidosis, uncompensated
C) Respiratory acidosis with full metabolic compensation
D) Mixed respiratory and metabolic acidosis
Correct answer: A
Explanation:
• pH 7.29 → Acidotic (<7.35)
• PaCO2 52 → Elevated = respiratory cause (CO2 retention from impaired gas exchange)
• HCO3- 24 → Normal range (22-26) = kidneys have NOT begun compensating
• Conclusion: Respiratory acidosis, uncompensated — consistent with pneumonia impairing ventilation
• (B) Metabolic acidosis would show decreased HCO3- with normal PaCO2
• (C) Full compensation would show HCO3- elevated above normal range AND pH returning toward 7.35-7.45
• (D) Mixed acidosis would show both elevated PaCO2 AND decreased HCO3-
NCLEX Category: Physiological Integrity — Physiological Adaptation Cognitive Level:
Analysis
Question 4
A nurse is assessing a client with a chest tube connected to a water-seal drainage system. Which finding
requires IMMEDIATE intervention?
A) Continuous bubbling in the water-seal chamber
B) Tidaling (fluctuation) in the water-seal chamber during respiration
C) 50 mL of serosanguineous drainage in the collection chamber over 2 hours
D) The drainage system is positioned below the level of the chest
Correct answer: A
Explanation:
3|Page
, • Continuous bubbling in the water-seal chamber indicates an air leak in the system — this requires immediate
investigation
• Air leak sources: connection sites, tubing crack, or ongoing bronchopleural fistula — assess all
connections first, then notify provider
• (B) Tidaling is EXPECTED and indicates the system is patent — absence of tidaling may indicate lung re-expansion
or obstruction
• (C) 50 mL over 2 hours is within acceptable range — drainage >100 mL/hr is concerning and requires notification
• (D) Drainage system SHOULD be below chest level to facilitate gravity drainage — this is correct positioning
NCLEX Category: Physiological Integrity — Reduction of Risk Potential Cognitive
Level: Analysis
Question 5
A client is admitted with suspected tuberculosis (TB). Which combination of actions should the nurse
implement? (Select All That Apply)
A) Place client in a negative-pressure airborne isolation room
B) Wear an N95 respirator when entering the room
C) Obtain three sputum specimens for acid-fast bacilli (AFB) on consecutive mornings
D) Administer BCG vaccine to the client immediately
E) Initiate a 4-drug regimen: INH, rifampin, pyrazinamide, and ethambutol as ordered
F) Place a surgical mask on the client during transport
Correct answer: A, B, C, E, F
Explanation:
• (A) Negative-pressure airborne isolation is mandatory for suspected/confirmed TB — prevents airborne
Mycobacterium tuberculosis from escaping the room
• (B) N95 respirator (not surgical mask) is required for healthcare workers — TB particles are 1-5 microns,
requiring N95 filtration
• (C) Three consecutive morning sputum specimens are standard for AFB smear and culture — morning specimens
yield highest organism concentration
• (D) BCG vaccine is a PREVENTIVE vaccine used in endemic countries — it is NOT a treatment for active TB and is
not routinely given in the U.S.
• (E) Standard initial TB treatment is RIPE therapy (Rifampin, INH, Pyrazinamide, Ethambutol) for the intensive
phase
• (F) Surgical mask on the CLIENT during transport reduces droplet nuclei dispersal — protects others in the facility
NCLEX Category: Safe & Effective Care Environment — Safety & Infection Control Cognitive Level:
Application
SECTION 2: CARDIAC & VASCULAR MANAGEMENT
4|Page
