NCLEX RN Clinical Judgment Exam 3
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
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Questions 1-10: Medical-Surgical Nursing
1. A client with heart failure is receiving furosemide (Lasix). Which assessment
finding indicates the medication is effective?
a) Decreased blood pressure
b) Weight loss of 2 pounds in 24 hours
c) Increased heart rate
d) Decreased urine output
Correct Answer: b
Rationale: Furosemide is a loop diuretic used to reduce fluid volume in heart failure.
A weight loss of 1-2 pounds per day indicates effective diuresis and reduction of
fluid overload. Decreased blood pressure is an expected side effect but does not
directly indicate therapeutic effectiveness. Increased heart rate may indicate
dehydration or compensatory response. Decreased urine output indicates the
medication is NOT effective.
2. A client with chronic obstructive pulmonary disease (COPD) has an arterial blood
gas (ABG) showing pH 7.32, PaCO2 58 mmHg, HCO3 30 mEq/L. The nurse
interprets these findings as:
a) Uncompensated respiratory acidosis
b) Partially compensated respiratory acidosis
,c) Fully compensated respiratory acidosis
d) Metabolic alkalosis
Correct Answer: b
Rationale: The ABG shows pH below normal (7.35-7.45), PaCO2 above normal (35-
45 mmHg), and HCO3 above normal (22-26 mEq/L). The low pH indicates acidosis,
elevated PaCO2 indicates respiratory cause, and elevated HCO3 indicates metabolic
compensation. Since the pH is still abnormal, this is partially compensated
respiratory acidosis.
3. A client is receiving heparin infusion for deep vein thrombosis. Which laboratory
value requires immediate nursing intervention?
a) Platelet count 250,000/mm³
b) Activated partial thromboplastin time (aPTT) 85 seconds
c) Hemoglobin 14 g/dL
d) INR 1.0
Correct Answer: b
Rationale: The therapeutic aPTT for heparin is typically 1.5-2.5 times the normal
control (about 60-80 seconds). An aPTT of 85 seconds indicates excessive
anticoagulation and increased bleeding risk. The nurse should notify the healthcare
provider and prepare to adjust the heparin infusion rate. Platelet count of 250,000
is normal. Hemoglobin 14 g/dL is normal. INR 1.0 is normal for a client not on
warfarin.
4. A client with diabetes mellitus type 2 is prescribed metformin. The nurse should
include which instruction in client teaching?
a) Take the medication with meals
b) Monitor for signs of hypoglycemia frequently
c) Expect weight gain as a side effect
d) Take the medication at bedtime
,Correct Answer: a
Rationale: Metformin should be taken with meals to reduce gastrointestinal side
effects such as nausea and diarrhea. Metformin does not typically cause
hypoglycemia when used alone. Weight loss is more common than weight gain with
metformin. Bedtime dosing is not specifically recommended.
5. A client is 2 days post-operative after a total hip replacement. Which finding
requires immediate nursing action?
a) Pain rated 4 on a 0-10 scale
b) Temperature 99.2°F (37.3°C)
c) Sudden shortness of breath and chest pain
d) Incision site with minimal serosanguineous drainage
Correct Answer: c
Rationale: Sudden shortness of breath and chest pain in a post-operative client are
classic signs of a pulmonary embolism, which is a life-threatening emergency. The
nurse should immediately assess, position the client in high Fowler's, apply oxygen,
and notify the healthcare provider. Pain rated 4/10 requires intervention but is not
immediately life-threatening. A low-grade fever is common post-operatively.
Minimal serosanguineous drainage is expected.
6. A client with acute pancreatitis is NPO and has a nasogastric tube to suction.
Which finding indicates the client is experiencing a complication?
a) Serum amylase 200 U/L
b) Serum lipase 180 U/L
c) Serum calcium 7.5 mg/dL
d) Serum glucose 120 mg/dL
Correct Answer: c
Rationale: Hypocalcemia (normal 8.5-10.5 mg/dL) in acute pancreatitis indicates fat
necrosis, which binds calcium. This is a serious complication requiring prompt
, intervention. Serum amylase of 200 U/L is elevated but expected. Serum lipase of
180 U/L is elevated but expected. Serum glucose of 120 mg/dL is slightly elevated
but not the most concerning finding.
7. The nurse is caring for a client with a stage III pressure injury on the sacrum.
Which wound care intervention is most appropriate?
a) Apply a transparent film dressing
b) Pack the wound with wet-to-dry saline gauze
c) Use a hydrocolloid dressing
d) Apply a calcium alginate dressing for moderate drainage
Correct Answer: d
Rationale: Stage III pressure injuries have full-thickness tissue loss with moderate to
heavy drainage. Calcium alginate dressings absorb excess exudate and maintain a
moist wound environment. Transparent film dressings are for superficial wounds.
Wet-to-dry gauze is an older method that can damage granulation tissue.
Hydrocolloid dressings are for wounds with minimal drainage.
8. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis.
Which medication should the nurse withhold before dialysis?
a) Iron supplement
b) Phosphate binder
c) Antihypertensive medication
d) Erythropoietin
Correct Answer: c
Rationale: Antihypertensive medications are often held before hemodialysis
because hypotension is a common complication during dialysis as fluid is removed.
Iron supplements, phosphate binders, and erythropoietin are generally not held
specifically for dialysis.
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
Questions 1-10: Medical-Surgical Nursing
1. A client with heart failure is receiving furosemide (Lasix). Which assessment
finding indicates the medication is effective?
a) Decreased blood pressure
b) Weight loss of 2 pounds in 24 hours
c) Increased heart rate
d) Decreased urine output
Correct Answer: b
Rationale: Furosemide is a loop diuretic used to reduce fluid volume in heart failure.
A weight loss of 1-2 pounds per day indicates effective diuresis and reduction of
fluid overload. Decreased blood pressure is an expected side effect but does not
directly indicate therapeutic effectiveness. Increased heart rate may indicate
dehydration or compensatory response. Decreased urine output indicates the
medication is NOT effective.
2. A client with chronic obstructive pulmonary disease (COPD) has an arterial blood
gas (ABG) showing pH 7.32, PaCO2 58 mmHg, HCO3 30 mEq/L. The nurse
interprets these findings as:
a) Uncompensated respiratory acidosis
b) Partially compensated respiratory acidosis
,c) Fully compensated respiratory acidosis
d) Metabolic alkalosis
Correct Answer: b
Rationale: The ABG shows pH below normal (7.35-7.45), PaCO2 above normal (35-
45 mmHg), and HCO3 above normal (22-26 mEq/L). The low pH indicates acidosis,
elevated PaCO2 indicates respiratory cause, and elevated HCO3 indicates metabolic
compensation. Since the pH is still abnormal, this is partially compensated
respiratory acidosis.
3. A client is receiving heparin infusion for deep vein thrombosis. Which laboratory
value requires immediate nursing intervention?
a) Platelet count 250,000/mm³
b) Activated partial thromboplastin time (aPTT) 85 seconds
c) Hemoglobin 14 g/dL
d) INR 1.0
Correct Answer: b
Rationale: The therapeutic aPTT for heparin is typically 1.5-2.5 times the normal
control (about 60-80 seconds). An aPTT of 85 seconds indicates excessive
anticoagulation and increased bleeding risk. The nurse should notify the healthcare
provider and prepare to adjust the heparin infusion rate. Platelet count of 250,000
is normal. Hemoglobin 14 g/dL is normal. INR 1.0 is normal for a client not on
warfarin.
4. A client with diabetes mellitus type 2 is prescribed metformin. The nurse should
include which instruction in client teaching?
a) Take the medication with meals
b) Monitor for signs of hypoglycemia frequently
c) Expect weight gain as a side effect
d) Take the medication at bedtime
,Correct Answer: a
Rationale: Metformin should be taken with meals to reduce gastrointestinal side
effects such as nausea and diarrhea. Metformin does not typically cause
hypoglycemia when used alone. Weight loss is more common than weight gain with
metformin. Bedtime dosing is not specifically recommended.
5. A client is 2 days post-operative after a total hip replacement. Which finding
requires immediate nursing action?
a) Pain rated 4 on a 0-10 scale
b) Temperature 99.2°F (37.3°C)
c) Sudden shortness of breath and chest pain
d) Incision site with minimal serosanguineous drainage
Correct Answer: c
Rationale: Sudden shortness of breath and chest pain in a post-operative client are
classic signs of a pulmonary embolism, which is a life-threatening emergency. The
nurse should immediately assess, position the client in high Fowler's, apply oxygen,
and notify the healthcare provider. Pain rated 4/10 requires intervention but is not
immediately life-threatening. A low-grade fever is common post-operatively.
Minimal serosanguineous drainage is expected.
6. A client with acute pancreatitis is NPO and has a nasogastric tube to suction.
Which finding indicates the client is experiencing a complication?
a) Serum amylase 200 U/L
b) Serum lipase 180 U/L
c) Serum calcium 7.5 mg/dL
d) Serum glucose 120 mg/dL
Correct Answer: c
Rationale: Hypocalcemia (normal 8.5-10.5 mg/dL) in acute pancreatitis indicates fat
necrosis, which binds calcium. This is a serious complication requiring prompt
, intervention. Serum amylase of 200 U/L is elevated but expected. Serum lipase of
180 U/L is elevated but expected. Serum glucose of 120 mg/dL is slightly elevated
but not the most concerning finding.
7. The nurse is caring for a client with a stage III pressure injury on the sacrum.
Which wound care intervention is most appropriate?
a) Apply a transparent film dressing
b) Pack the wound with wet-to-dry saline gauze
c) Use a hydrocolloid dressing
d) Apply a calcium alginate dressing for moderate drainage
Correct Answer: d
Rationale: Stage III pressure injuries have full-thickness tissue loss with moderate to
heavy drainage. Calcium alginate dressings absorb excess exudate and maintain a
moist wound environment. Transparent film dressings are for superficial wounds.
Wet-to-dry gauze is an older method that can damage granulation tissue.
Hydrocolloid dressings are for wounds with minimal drainage.
8. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis.
Which medication should the nurse withhold before dialysis?
a) Iron supplement
b) Phosphate binder
c) Antihypertensive medication
d) Erythropoietin
Correct Answer: c
Rationale: Antihypertensive medications are often held before hemodialysis
because hypotension is a common complication during dialysis as fluid is removed.
Iron supplements, phosphate binders, and erythropoietin are generally not held
specifically for dialysis.
