NCLEX-RN Clinical Judgment Exam 1
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
1. A nurse is caring for a client who is 2 days post-operative following an abdominal
hysterectomy. The client reports a sudden onset of sharp chest pain and shortness
of breath. The nurse's priority action is to:
A. Administer the prescribed PRN pain medication.
B. Apply oxygen via nasal cannula.
C. Assess the client's vital signs.
D. Prepare the client for a ventilation-perfusion scan.
Correct Answer: B
Rationale: The client is exhibiting signs of a potential pulmonary embolism (sudden
chest pain and dyspnea). The immediate priority is to ensure adequate oxygenation.
The nurse should apply oxygen and then assess vital signs and notify the provider.
Pain medication, while important, is secondary to addressing the life-threatening
hypoxia. A V/Q scan is a diagnostic procedure ordered by a provider.
2. A client with a history of heart failure is admitted with shortness of breath,
crackles in the lung bases, and 3+ pitting edema in the lower extremities. Which
laboratory value is the most important for the nurse to monitor?
A. Serum sodium
B. Serum potassium
C. B-type natriuretic peptide (BNP)
D. Serum creatinine
,Correct Answer: C
Rationale: BNP is a hormone secreted by the ventricles in response to increased
pressure and volume. An elevated BNP level is a sensitive and specific indicator of
heart failure and can be used to monitor the severity of the condition and response
to treatment. While sodium, potassium, and creatinine are also important to
monitor, BNP is the most specific indicator of heart failure exacerbation.
3. A nurse is preparing to administer an intermittent enteral feeding to a client via a
nasogastric (NG) tube. Which action should the nurse take first?
A. Flush the tube with 30 mL of water.
B. Verify the tube placement by aspirating gastric contents and checking the pH.
C. Elevate the head of the bed to at least 30 degrees.
D. Check the residual volume.
Correct Answer: B
Rationale: The first step before administering any enteral feeding is to confirm the
correct placement of the NG tube. This is done by aspirating gastric contents and
checking the pH (should be ≤ 4.0) to prevent accidental administration into the
lungs. While flushing, elevating the HOB, and checking residual are important steps
in the administration process, verifying placement is the priority for safety.
4. A client with diabetes mellitus type 1 is experiencing nausea and vomiting and is
unable to tolerate oral intake. The client's blood glucose is 280 mg/dL, and urine
ketones are large. The nurse anticipates the provider will order which intervention?
A. Administer oral glucose gel.
B. Administer regular insulin subcutaneously.
C. Administer an antiemetic and encourage clear liquids.
D. Start an IV of normal saline and regular insulin infusion.
Correct Answer: D
Rationale: The client is exhibiting signs of diabetic ketoacidosis (DKA) with
hyperglycemia, ketones, and an inability to take in fluids. This is a medical
,emergency requiring IV fluid resuscitation (normal saline) to correct dehydration
and an IV insulin infusion to lower blood glucose. Subcutaneous insulin is ineffective
in DKA due to poor tissue perfusion. Oral glucose is contraindicated.
5. A nurse is providing discharge teaching to a client with a new prescription for
warfarin. Which client statement indicates the need for further teaching?
A. "I will avoid eating large amounts of green leafy vegetables."
B. "I will use a soft-bristled toothbrush to brush my teeth."
C. "I will take ibuprofen for my headaches instead of acetaminophen."
D. "I will report any bruises or bleeding to my healthcare provider."
Correct Answer: C
Rationale: Ibuprofen (an NSAID) can increase the risk of bleeding and should be
avoided while taking warfarin. Acetaminophen is the preferred analgesic. The other
statements indicate understanding: limiting vitamin K-rich foods (like green leafy
vegetables), using a soft toothbrush to prevent gum bleeding, and reporting signs
of bleeding are all correct.
6. A client is brought to the emergency department following a motor vehicle
accident. The client is combative and confused. The nurse notes a blood pressure
of 100/60 mmHg, heart rate of 110 bpm, and cool, clammy skin. Which acid-base
imbalance does the nurse suspect?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
Rationale: The client is showing signs of hypovolemic shock following trauma
(hypotension, tachycardia, cool, clammy skin). This leads to poor tissue perfusion
and anaerobic metabolism, which produces lactic acid, resulting in metabolic
, acidosis. Respiratory acidosis is from hypoventilation, while respiratory alkalosis is
from hyperventilation.
7. A nurse is caring for a client with a chest tube connected to a water-seal
drainage system. The nurse notes continuous bubbling in the water-seal chamber.
What is the most appropriate action?
A. Document the finding as normal.
B. Clamp the chest tube immediately.
C. Assess the system for an air leak.
D. Increase the suction pressure.
Correct Answer: C
Rationale: Intermittent bubbling in the water-seal chamber is normal and reflects
air being expelled from the pleural space. Continuous bubbling indicates an air leak
in the system. The nurse should first assess the system (check connections, drainage
tubing) to locate the source of the leak. Clamping the tube is dangerous and should
only be done briefly to find a leak. Increasing suction will not fix an air leak.
8. A client with chronic obstructive pulmonary disease (COPD) has a prescription
for 2 L/min of oxygen via nasal cannula. The nurse is caring for a client with COPD.
Which is the most important to monitor when determining the effectiveness of this
therapy?
A. Respiratory rate
B. Level of consciousness
C. Arterial blood gas (ABG) results
D. Pulse oximetry
Correct Answer: C
Rationale: For clients with COPD, the hypoxic drive is a concern. The goal is to
maintain oxygen saturation at 88-92% to avoid suppressing the respiratory drive.
The most reliable indicator of the effectiveness of oxygen therapy and acid-base
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
1. A nurse is caring for a client who is 2 days post-operative following an abdominal
hysterectomy. The client reports a sudden onset of sharp chest pain and shortness
of breath. The nurse's priority action is to:
A. Administer the prescribed PRN pain medication.
B. Apply oxygen via nasal cannula.
C. Assess the client's vital signs.
D. Prepare the client for a ventilation-perfusion scan.
Correct Answer: B
Rationale: The client is exhibiting signs of a potential pulmonary embolism (sudden
chest pain and dyspnea). The immediate priority is to ensure adequate oxygenation.
The nurse should apply oxygen and then assess vital signs and notify the provider.
Pain medication, while important, is secondary to addressing the life-threatening
hypoxia. A V/Q scan is a diagnostic procedure ordered by a provider.
2. A client with a history of heart failure is admitted with shortness of breath,
crackles in the lung bases, and 3+ pitting edema in the lower extremities. Which
laboratory value is the most important for the nurse to monitor?
A. Serum sodium
B. Serum potassium
C. B-type natriuretic peptide (BNP)
D. Serum creatinine
,Correct Answer: C
Rationale: BNP is a hormone secreted by the ventricles in response to increased
pressure and volume. An elevated BNP level is a sensitive and specific indicator of
heart failure and can be used to monitor the severity of the condition and response
to treatment. While sodium, potassium, and creatinine are also important to
monitor, BNP is the most specific indicator of heart failure exacerbation.
3. A nurse is preparing to administer an intermittent enteral feeding to a client via a
nasogastric (NG) tube. Which action should the nurse take first?
A. Flush the tube with 30 mL of water.
B. Verify the tube placement by aspirating gastric contents and checking the pH.
C. Elevate the head of the bed to at least 30 degrees.
D. Check the residual volume.
Correct Answer: B
Rationale: The first step before administering any enteral feeding is to confirm the
correct placement of the NG tube. This is done by aspirating gastric contents and
checking the pH (should be ≤ 4.0) to prevent accidental administration into the
lungs. While flushing, elevating the HOB, and checking residual are important steps
in the administration process, verifying placement is the priority for safety.
4. A client with diabetes mellitus type 1 is experiencing nausea and vomiting and is
unable to tolerate oral intake. The client's blood glucose is 280 mg/dL, and urine
ketones are large. The nurse anticipates the provider will order which intervention?
A. Administer oral glucose gel.
B. Administer regular insulin subcutaneously.
C. Administer an antiemetic and encourage clear liquids.
D. Start an IV of normal saline and regular insulin infusion.
Correct Answer: D
Rationale: The client is exhibiting signs of diabetic ketoacidosis (DKA) with
hyperglycemia, ketones, and an inability to take in fluids. This is a medical
,emergency requiring IV fluid resuscitation (normal saline) to correct dehydration
and an IV insulin infusion to lower blood glucose. Subcutaneous insulin is ineffective
in DKA due to poor tissue perfusion. Oral glucose is contraindicated.
5. A nurse is providing discharge teaching to a client with a new prescription for
warfarin. Which client statement indicates the need for further teaching?
A. "I will avoid eating large amounts of green leafy vegetables."
B. "I will use a soft-bristled toothbrush to brush my teeth."
C. "I will take ibuprofen for my headaches instead of acetaminophen."
D. "I will report any bruises or bleeding to my healthcare provider."
Correct Answer: C
Rationale: Ibuprofen (an NSAID) can increase the risk of bleeding and should be
avoided while taking warfarin. Acetaminophen is the preferred analgesic. The other
statements indicate understanding: limiting vitamin K-rich foods (like green leafy
vegetables), using a soft toothbrush to prevent gum bleeding, and reporting signs
of bleeding are all correct.
6. A client is brought to the emergency department following a motor vehicle
accident. The client is combative and confused. The nurse notes a blood pressure
of 100/60 mmHg, heart rate of 110 bpm, and cool, clammy skin. Which acid-base
imbalance does the nurse suspect?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
Rationale: The client is showing signs of hypovolemic shock following trauma
(hypotension, tachycardia, cool, clammy skin). This leads to poor tissue perfusion
and anaerobic metabolism, which produces lactic acid, resulting in metabolic
, acidosis. Respiratory acidosis is from hypoventilation, while respiratory alkalosis is
from hyperventilation.
7. A nurse is caring for a client with a chest tube connected to a water-seal
drainage system. The nurse notes continuous bubbling in the water-seal chamber.
What is the most appropriate action?
A. Document the finding as normal.
B. Clamp the chest tube immediately.
C. Assess the system for an air leak.
D. Increase the suction pressure.
Correct Answer: C
Rationale: Intermittent bubbling in the water-seal chamber is normal and reflects
air being expelled from the pleural space. Continuous bubbling indicates an air leak
in the system. The nurse should first assess the system (check connections, drainage
tubing) to locate the source of the leak. Clamping the tube is dangerous and should
only be done briefly to find a leak. Increasing suction will not fix an air leak.
8. A client with chronic obstructive pulmonary disease (COPD) has a prescription
for 2 L/min of oxygen via nasal cannula. The nurse is caring for a client with COPD.
Which is the most important to monitor when determining the effectiveness of this
therapy?
A. Respiratory rate
B. Level of consciousness
C. Arterial blood gas (ABG) results
D. Pulse oximetry
Correct Answer: C
Rationale: For clients with COPD, the hypoxic drive is a concern. The goal is to
maintain oxygen saturation at 88-92% to avoid suppressing the respiratory drive.
The most reliable indicator of the effectiveness of oxygen therapy and acid-base
