NCLEX RN Clinical Judgment Exam 2
100 Questions And Correct Answers
(Verified Answers) Plus Rationales
2026 Q&A Instant Download Pdf
Questions 1–10
1. A client with pneumonia has a respiratory rate of 30/min, oxygen
saturation of 88% on room air, and increasing confusion. Which action
should the nurse take first?
A. Obtain a sputum specimen
B. Encourage oral fluids
C. Apply supplemental oxygen
D. Administer the prescribed antibiotic
Answer: C. Apply supplemental oxygen
Rationale: Hypoxemia with acute confusion indicates impaired oxygenation.
The nurse should address airway and breathing immediately before
completing diagnostic or medication-related interventions.
2. A client with heart failure suddenly develops severe dyspnea, pink frothy
sputum, and bilateral crackles. Which prescription should the nurse
implement first?
A. Obtain a daily weight
B. Administer IV loop diuretic
C. Restrict oral sodium
D. Teach energy-conservation techniques
Answer: B. Administer IV loop diuretic
Rationale: The findings indicate acute pulmonary edema. Rapid diuresis
reduces pulmonary congestion and improves oxygenation.
, 3. A client with diabetes is diaphoretic, trembling, and confused. The blood
glucose is 48 mg/dL (2.7 mmol/L), and the client can swallow. What
should the nurse do?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Give a high-protein meal
D. Recheck glucose in 2 hours
Answer: B. Give 15 g of rapid-acting carbohydrate
Rationale: A conscious client who can swallow and has symptomatic
hypoglycemia should receive approximately 15 g of fast-acting carbohydrate,
followed by reassessment.
4. A client receiving a blood transfusion develops chills, fever, and low back
pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another unit of blood
Answer: B. Stop the transfusion
Rationale: These findings suggest an acute transfusion reaction. The
transfusion must be stopped immediately to prevent additional exposure.
5. A client with increased intracranial pressure has a declining level of
consciousness. Which intervention is most appropriate?
A. Keep the neck flexed
B. Position the head of the bed about 30 degrees
C. Encourage frequent coughing
D. Place the client in Trendelenburg position
Answer: B. Position the head of the bed about 30 degrees
Rationale: Elevating the head and maintaining neutral neck alignment
promotes venous drainage and can help reduce intracranial pressure.
6. A postoperative client reports sudden chest pain and shortness of
breath. The heart rate is 124/min and oxygen saturation is 84%. Which
, complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Hypoglycemia
D. Fluid overload
Answer: B. Pulmonary embolism
Rationale: Sudden dyspnea, chest pain, tachycardia, and hypoxemia are
classic findings associated with pulmonary embolism, particularly after
surgery.
7. A client with chronic kidney disease has a potassium level of 6.8 mEq/L
(6.8 mmol/L) and peaked T waves on the ECG. Which intervention is the
priority?
A. Encourage potassium-rich foods
B. Place the client on cardiac monitoring
C. Administer oral iron
D. Restrict protein intake
Answer: B. Place the client on cardiac monitoring
Rationale: Severe hyperkalemia can cause life-threatening cardiac
dysrhythmias. Continuous cardiac monitoring is essential while urgent
treatment is initiated.
8. A client with suspected stroke arrives within the treatment window.
Which assessment finding is most important to obtain immediately?
A. Last known well time
B. Dietary preferences
C. Usual sleep pattern
D. Family medical history
Answer: A. Last known well time
Rationale: The time the client was last known to be neurologically normal is
critical for determining eligibility for time-sensitive stroke therapies.
9. A client receiving IV morphine becomes difficult to arouse and has a
respiratory rate of 7/min. Which medication should the nurse anticipate
, administering?
A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Answer: B. Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse opioid-induced
respiratory depression.
10.A client with a gastrointestinal hemorrhage has a blood pressure of
82/48 mm Hg and a heart rate of 132/min. Which finding requires
immediate intervention?
A. Mild abdominal discomfort
B. Tachycardia and hypotension
C. Dark stool
D. Fatigue
Answer: B. Tachycardia and hypotension
Rationale: Tachycardia and severe hypotension indicate hemodynamic
instability and possible hypovolemic shock from blood loss.
Questions 11–20
11.A client with COPD is receiving oxygen therapy. Which finding requires
the most immediate attention?
A. Oxygen saturation of 90%
B. Respiratory rate of 20/min
C. Increasing somnolence and difficulty arousing
D. Productive cough
Answer: C. Increasing somnolence and difficulty arousing
Rationale: Increasing somnolence may indicate worsening carbon dioxide
retention or respiratory failure and requires immediate assessment and
intervention.
100 Questions And Correct Answers
(Verified Answers) Plus Rationales
2026 Q&A Instant Download Pdf
Questions 1–10
1. A client with pneumonia has a respiratory rate of 30/min, oxygen
saturation of 88% on room air, and increasing confusion. Which action
should the nurse take first?
A. Obtain a sputum specimen
B. Encourage oral fluids
C. Apply supplemental oxygen
D. Administer the prescribed antibiotic
Answer: C. Apply supplemental oxygen
Rationale: Hypoxemia with acute confusion indicates impaired oxygenation.
The nurse should address airway and breathing immediately before
completing diagnostic or medication-related interventions.
2. A client with heart failure suddenly develops severe dyspnea, pink frothy
sputum, and bilateral crackles. Which prescription should the nurse
implement first?
A. Obtain a daily weight
B. Administer IV loop diuretic
C. Restrict oral sodium
D. Teach energy-conservation techniques
Answer: B. Administer IV loop diuretic
Rationale: The findings indicate acute pulmonary edema. Rapid diuresis
reduces pulmonary congestion and improves oxygenation.
, 3. A client with diabetes is diaphoretic, trembling, and confused. The blood
glucose is 48 mg/dL (2.7 mmol/L), and the client can swallow. What
should the nurse do?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Give a high-protein meal
D. Recheck glucose in 2 hours
Answer: B. Give 15 g of rapid-acting carbohydrate
Rationale: A conscious client who can swallow and has symptomatic
hypoglycemia should receive approximately 15 g of fast-acting carbohydrate,
followed by reassessment.
4. A client receiving a blood transfusion develops chills, fever, and low back
pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another unit of blood
Answer: B. Stop the transfusion
Rationale: These findings suggest an acute transfusion reaction. The
transfusion must be stopped immediately to prevent additional exposure.
5. A client with increased intracranial pressure has a declining level of
consciousness. Which intervention is most appropriate?
A. Keep the neck flexed
B. Position the head of the bed about 30 degrees
C. Encourage frequent coughing
D. Place the client in Trendelenburg position
Answer: B. Position the head of the bed about 30 degrees
Rationale: Elevating the head and maintaining neutral neck alignment
promotes venous drainage and can help reduce intracranial pressure.
6. A postoperative client reports sudden chest pain and shortness of
breath. The heart rate is 124/min and oxygen saturation is 84%. Which
, complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Hypoglycemia
D. Fluid overload
Answer: B. Pulmonary embolism
Rationale: Sudden dyspnea, chest pain, tachycardia, and hypoxemia are
classic findings associated with pulmonary embolism, particularly after
surgery.
7. A client with chronic kidney disease has a potassium level of 6.8 mEq/L
(6.8 mmol/L) and peaked T waves on the ECG. Which intervention is the
priority?
A. Encourage potassium-rich foods
B. Place the client on cardiac monitoring
C. Administer oral iron
D. Restrict protein intake
Answer: B. Place the client on cardiac monitoring
Rationale: Severe hyperkalemia can cause life-threatening cardiac
dysrhythmias. Continuous cardiac monitoring is essential while urgent
treatment is initiated.
8. A client with suspected stroke arrives within the treatment window.
Which assessment finding is most important to obtain immediately?
A. Last known well time
B. Dietary preferences
C. Usual sleep pattern
D. Family medical history
Answer: A. Last known well time
Rationale: The time the client was last known to be neurologically normal is
critical for determining eligibility for time-sensitive stroke therapies.
9. A client receiving IV morphine becomes difficult to arouse and has a
respiratory rate of 7/min. Which medication should the nurse anticipate
, administering?
A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Answer: B. Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse opioid-induced
respiratory depression.
10.A client with a gastrointestinal hemorrhage has a blood pressure of
82/48 mm Hg and a heart rate of 132/min. Which finding requires
immediate intervention?
A. Mild abdominal discomfort
B. Tachycardia and hypotension
C. Dark stool
D. Fatigue
Answer: B. Tachycardia and hypotension
Rationale: Tachycardia and severe hypotension indicate hemodynamic
instability and possible hypovolemic shock from blood loss.
Questions 11–20
11.A client with COPD is receiving oxygen therapy. Which finding requires
the most immediate attention?
A. Oxygen saturation of 90%
B. Respiratory rate of 20/min
C. Increasing somnolence and difficulty arousing
D. Productive cough
Answer: C. Increasing somnolence and difficulty arousing
Rationale: Increasing somnolence may indicate worsening carbon dioxide
retention or respiratory failure and requires immediate assessment and
intervention.
