NSG 3100 NCLEX Practice Exam — Exam
Questions with Correct Answers
(VerifiedAnswers) Plus Rationales 2026 Q&A
Instant Download PDF
Question 1
A nurse is caring for a client who has just returned from surgery.
Which assessment finding requires the nurse's priority
intervention?
A. Pain rated 6/10
B. Temperature of 37.6°C (99.7°F)
C. Oxygen saturation of 88% on room air
D. Urine output of 40 mL/hr
Correct answer: C. Oxygen saturation of 88% on room air
Rationale: Airway and breathing problems take priority
according to the ABC framework. An oxygen saturation of 88%
indicates clinically significant hypoxemia and requires prompt
assessment and intervention. The nurse should assess
respiratory effort, airway patency, lung sounds, and oxygen
delivery while following prescribed oxygen therapy and
institutional protocols. A pain rating of 6/10 requires treatment
,but is not the immediate priority over impaired oxygenation. A
temperature of 37.6°C is not concerning for a postoperative
fever, and urine output of 40 mL/hr is generally acceptable for
an adult, depending on the client's weight and clinical condition.
Question 2
A client with heart failure is prescribed furosemide. Which
laboratory value should the nurse monitor most closely?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Correct answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
excretion of sodium and water and can also cause significant
potassium loss. Hypokalemia may produce muscle weakness,
cardiac dysrhythmias, and potentially life-threatening
complications. The nurse should monitor serum potassium and
assess for manifestations such as weakness, muscle cramps, and
abnormal cardiac rhythms. Calcium can also be affected by loop
diuretics, but potassium is a particularly important safety
concern because of its effects on cardiac conduction.
,Question 3
A nurse is teaching a client who has been prescribed warfarin.
Which statement by the client indicates correct understanding?
A. "I should avoid all foods containing vitamin K."
B. "I can stop the medication when my bruising improves."
C. "I should keep my intake of vitamin K-containing foods
consistent."
D. "I should take aspirin daily to increase the medication's
effectiveness."
Correct answer: C. "I should keep my intake of vitamin K-
containing foods consistent."
Rationale: Warfarin's effectiveness is influenced by vitamin K
intake. Clients do not necessarily need to eliminate vitamin K-
containing foods, but they should maintain a consistent dietary
intake so anticoagulation remains predictable. Abrupt increases
or decreases in vitamin K intake can alter the international
normalized ratio (INR). Clients should also avoid taking
additional medications or supplements that increase bleeding
risk unless approved by the prescriber. Warfarin should not be
stopped independently, and aspirin can increase bleeding risk.
Question 4
, A nurse enters the room of a client with diabetes mellitus and
finds the client diaphoretic, trembling, and confused. What is
the nurse's priority action?
A. Administer prescribed long-acting insulin
B. Check the client's blood glucose level
C. Encourage the client to ambulate
D. Restrict oral fluids
Correct answer: B. Check the client's blood glucose level
Rationale: Diaphoresis, tremors, and confusion are classic
manifestations of hypoglycemia. The nurse should promptly
check the blood glucose level if a glucometer is immediately
available. If hypoglycemia is confirmed and the client is
conscious and able to swallow, a rapid-acting carbohydrate
should generally be provided according to the treatment
protocol. If the client is unconscious or unable to swallow safely,
oral glucose should not be given because of aspiration risk.
Administering insulin would worsen hypoglycemia.
Question 5
Which intervention is most appropriate for a client experiencing
a seizure?
A. Place a tongue blade in the client's mouth
B. Restrain the client's extremities
Questions with Correct Answers
(VerifiedAnswers) Plus Rationales 2026 Q&A
Instant Download PDF
Question 1
A nurse is caring for a client who has just returned from surgery.
Which assessment finding requires the nurse's priority
intervention?
A. Pain rated 6/10
B. Temperature of 37.6°C (99.7°F)
C. Oxygen saturation of 88% on room air
D. Urine output of 40 mL/hr
Correct answer: C. Oxygen saturation of 88% on room air
Rationale: Airway and breathing problems take priority
according to the ABC framework. An oxygen saturation of 88%
indicates clinically significant hypoxemia and requires prompt
assessment and intervention. The nurse should assess
respiratory effort, airway patency, lung sounds, and oxygen
delivery while following prescribed oxygen therapy and
institutional protocols. A pain rating of 6/10 requires treatment
,but is not the immediate priority over impaired oxygenation. A
temperature of 37.6°C is not concerning for a postoperative
fever, and urine output of 40 mL/hr is generally acceptable for
an adult, depending on the client's weight and clinical condition.
Question 2
A client with heart failure is prescribed furosemide. Which
laboratory value should the nurse monitor most closely?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Correct answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
excretion of sodium and water and can also cause significant
potassium loss. Hypokalemia may produce muscle weakness,
cardiac dysrhythmias, and potentially life-threatening
complications. The nurse should monitor serum potassium and
assess for manifestations such as weakness, muscle cramps, and
abnormal cardiac rhythms. Calcium can also be affected by loop
diuretics, but potassium is a particularly important safety
concern because of its effects on cardiac conduction.
,Question 3
A nurse is teaching a client who has been prescribed warfarin.
Which statement by the client indicates correct understanding?
A. "I should avoid all foods containing vitamin K."
B. "I can stop the medication when my bruising improves."
C. "I should keep my intake of vitamin K-containing foods
consistent."
D. "I should take aspirin daily to increase the medication's
effectiveness."
Correct answer: C. "I should keep my intake of vitamin K-
containing foods consistent."
Rationale: Warfarin's effectiveness is influenced by vitamin K
intake. Clients do not necessarily need to eliminate vitamin K-
containing foods, but they should maintain a consistent dietary
intake so anticoagulation remains predictable. Abrupt increases
or decreases in vitamin K intake can alter the international
normalized ratio (INR). Clients should also avoid taking
additional medications or supplements that increase bleeding
risk unless approved by the prescriber. Warfarin should not be
stopped independently, and aspirin can increase bleeding risk.
Question 4
, A nurse enters the room of a client with diabetes mellitus and
finds the client diaphoretic, trembling, and confused. What is
the nurse's priority action?
A. Administer prescribed long-acting insulin
B. Check the client's blood glucose level
C. Encourage the client to ambulate
D. Restrict oral fluids
Correct answer: B. Check the client's blood glucose level
Rationale: Diaphoresis, tremors, and confusion are classic
manifestations of hypoglycemia. The nurse should promptly
check the blood glucose level if a glucometer is immediately
available. If hypoglycemia is confirmed and the client is
conscious and able to swallow, a rapid-acting carbohydrate
should generally be provided according to the treatment
protocol. If the client is unconscious or unable to swallow safely,
oral glucose should not be given because of aspiration risk.
Administering insulin would worsen hypoglycemia.
Question 5
Which intervention is most appropriate for a client experiencing
a seizure?
A. Place a tongue blade in the client's mouth
B. Restrain the client's extremities
