NCLEX RN Clinical Judgment Exam 3
100 Questions And Correct Answers
(Verified Answers) Plus Rationales
2026 Q&A Instant Download Pdf
Question 1
A nurse is caring for a client with heart failure who suddenly develops severe
dyspnea, crackles throughout both lung fields, and an oxygen saturation of
82%. Which action should the nurse take first?
A. Administer the prescribed IV diuretic
B. Place the client in high-Fowler's position
C. Obtain the client's daily weight
D. Restrict the client's oral fluids
Answer: B. Place the client in high-Fowler's position
Rationale: Positioning the client upright immediately improves lung
expansion and decreases venous return, helping relieve acute pulmonary
congestion. Medication administration and fluid restriction may follow after
immediate respiratory support is initiated.
Question 2
A client with diabetic ketoacidosis has a blood glucose of 540 mg/dL, potassium
of 5.8 mEq/L, and metabolic acidosis. Which prescription should the nurse
implement first?
A. IV regular insulin infusion
B. IV potassium chloride
C. Oral potassium replacement
D. Subcutaneous long-acting insulin
,Answer: A. IV regular insulin infusion
Rationale: IV regular insulin is a key treatment for diabetic ketoacidosis
because it stops ketone production and shifts potassium into cells. Potassium
replacement is not appropriate when the serum potassium is already
elevated.
Question 3
A client receiving a blood transfusion reports chills, low back pain, and chest
tightness. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another blood specimen
Answer: B. Stop the transfusion
Rationale: These findings may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the IV line
should be maintained with compatible normal saline according to protocol.
Question 4
A client with a head injury becomes increasingly confused and develops
unequal pupils. Which finding requires immediate intervention?
A. Mild headache
B. Blood pressure of 138/84 mmHg
C. New unequal pupils
D. Temperature of 37.4°C (99.3°F)
Answer: C. New unequal pupils
Rationale: New anisocoria with worsening mental status may indicate
increased intracranial pressure and possible cerebral herniation. This is a
neurologic emergency requiring immediate intervention.
,Question 5
A client with chronic obstructive pulmonary disease is receiving oxygen at 2
L/min by nasal cannula. The client becomes increasingly drowsy. Which action
is most appropriate?
A. Increase oxygen to 10 L/min
B. Assess respiratory status and oxygenation
C. Administer a sedative
D. Place the client flat
Answer: B. Assess respiratory status and oxygenation
Rationale: Increasing somnolence may indicate worsening hypercapnia or
respiratory failure. The nurse should immediately reassess respiratory status
and oxygenation rather than automatically increasing oxygen to a high
concentration.
Question 6
A client taking warfarin has an INR of 5.8 and reports bleeding gums. Which
prescription should the nurse question?
A. Hold warfarin
B. Assess for additional bleeding
C. Administer vitamin K as prescribed
D. Administer the next scheduled dose of warfarin
Answer: D. Administer the next scheduled dose of warfarin
Rationale: An INR of 5.8 with active bleeding indicates excessive
anticoagulation. The next warfarin dose should be withheld, and additional
treatment may include vitamin K depending on the severity of bleeding and
provider orders.
Question 7
, A client with suspected sepsis has a temperature of 39.2°C (102.6°F), heart rate
of 128/min, respiratory rate of 30/min, and blood pressure of 84/48 mmHg.
Which intervention has the highest priority?
A. Begin prescribed IV fluid resuscitation
B. Provide oral fluids
C. Encourage ambulation
D. Apply a warming blanket
Answer: A. Begin prescribed IV fluid resuscitation
Rationale: Hypotension in suspected sepsis suggests septic shock. Rapid IV
fluid resuscitation supports circulating volume and tissue perfusion and is a
priority intervention.
Question 8
A client with asthma has severe wheezing and is using accessory muscles to
breathe. Suddenly, the wheezing becomes absent. What should the nurse
recognize?
A. The asthma attack has resolved
B. The client is improving
C. Airflow obstruction may have become severe
D. The bronchodilator has worked completely
Answer: C. Airflow obstruction may have become severe
Rationale: A sudden absence of wheezing in a client with severe respiratory
distress can indicate minimal air movement, sometimes called a silent chest.
This is a potentially life-threatening finding.
Question 9
A client with acute kidney injury has a potassium level of 6.7 mEq/L and peaked
T waves on the ECG. Which prescription should the nurse implement first?
A. Administer IV calcium gluconate
B. Encourage high-potassium foods
100 Questions And Correct Answers
(Verified Answers) Plus Rationales
2026 Q&A Instant Download Pdf
Question 1
A nurse is caring for a client with heart failure who suddenly develops severe
dyspnea, crackles throughout both lung fields, and an oxygen saturation of
82%. Which action should the nurse take first?
A. Administer the prescribed IV diuretic
B. Place the client in high-Fowler's position
C. Obtain the client's daily weight
D. Restrict the client's oral fluids
Answer: B. Place the client in high-Fowler's position
Rationale: Positioning the client upright immediately improves lung
expansion and decreases venous return, helping relieve acute pulmonary
congestion. Medication administration and fluid restriction may follow after
immediate respiratory support is initiated.
Question 2
A client with diabetic ketoacidosis has a blood glucose of 540 mg/dL, potassium
of 5.8 mEq/L, and metabolic acidosis. Which prescription should the nurse
implement first?
A. IV regular insulin infusion
B. IV potassium chloride
C. Oral potassium replacement
D. Subcutaneous long-acting insulin
,Answer: A. IV regular insulin infusion
Rationale: IV regular insulin is a key treatment for diabetic ketoacidosis
because it stops ketone production and shifts potassium into cells. Potassium
replacement is not appropriate when the serum potassium is already
elevated.
Question 3
A client receiving a blood transfusion reports chills, low back pain, and chest
tightness. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another blood specimen
Answer: B. Stop the transfusion
Rationale: These findings may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the IV line
should be maintained with compatible normal saline according to protocol.
Question 4
A client with a head injury becomes increasingly confused and develops
unequal pupils. Which finding requires immediate intervention?
A. Mild headache
B. Blood pressure of 138/84 mmHg
C. New unequal pupils
D. Temperature of 37.4°C (99.3°F)
Answer: C. New unequal pupils
Rationale: New anisocoria with worsening mental status may indicate
increased intracranial pressure and possible cerebral herniation. This is a
neurologic emergency requiring immediate intervention.
,Question 5
A client with chronic obstructive pulmonary disease is receiving oxygen at 2
L/min by nasal cannula. The client becomes increasingly drowsy. Which action
is most appropriate?
A. Increase oxygen to 10 L/min
B. Assess respiratory status and oxygenation
C. Administer a sedative
D. Place the client flat
Answer: B. Assess respiratory status and oxygenation
Rationale: Increasing somnolence may indicate worsening hypercapnia or
respiratory failure. The nurse should immediately reassess respiratory status
and oxygenation rather than automatically increasing oxygen to a high
concentration.
Question 6
A client taking warfarin has an INR of 5.8 and reports bleeding gums. Which
prescription should the nurse question?
A. Hold warfarin
B. Assess for additional bleeding
C. Administer vitamin K as prescribed
D. Administer the next scheduled dose of warfarin
Answer: D. Administer the next scheduled dose of warfarin
Rationale: An INR of 5.8 with active bleeding indicates excessive
anticoagulation. The next warfarin dose should be withheld, and additional
treatment may include vitamin K depending on the severity of bleeding and
provider orders.
Question 7
, A client with suspected sepsis has a temperature of 39.2°C (102.6°F), heart rate
of 128/min, respiratory rate of 30/min, and blood pressure of 84/48 mmHg.
Which intervention has the highest priority?
A. Begin prescribed IV fluid resuscitation
B. Provide oral fluids
C. Encourage ambulation
D. Apply a warming blanket
Answer: A. Begin prescribed IV fluid resuscitation
Rationale: Hypotension in suspected sepsis suggests septic shock. Rapid IV
fluid resuscitation supports circulating volume and tissue perfusion and is a
priority intervention.
Question 8
A client with asthma has severe wheezing and is using accessory muscles to
breathe. Suddenly, the wheezing becomes absent. What should the nurse
recognize?
A. The asthma attack has resolved
B. The client is improving
C. Airflow obstruction may have become severe
D. The bronchodilator has worked completely
Answer: C. Airflow obstruction may have become severe
Rationale: A sudden absence of wheezing in a client with severe respiratory
distress can indicate minimal air movement, sometimes called a silent chest.
This is a potentially life-threatening finding.
Question 9
A client with acute kidney injury has a potassium level of 6.7 mEq/L and peaked
T waves on the ECG. Which prescription should the nurse implement first?
A. Administer IV calcium gluconate
B. Encourage high-potassium foods
