NCLEX-RN Comprehensive Practice
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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1. A nurse is caring for a client who is receiving digoxin. Which assessment
finding indicates a therapeutic response to the medication?
A. Heart rate 110 bpm
B. Heart rate 76 bpm and regular
C. Urine output 20 mL/hr
D. Blood pressure 150/90 mm Hg
Rationale: Digoxin slows the heart rate and improves contractility. A heart
rate of 76 bpm and regular indicates a therapeutic response. A heart rate of
110 bpm indicates the medication is not effectively controlling the rate. Urine
output of 20 mL/hr is below the expected 30 mL/hr and indicates a problem.
Blood pressure of 150/90 mm Hg is elevated and not a direct indicator of
digoxin therapy.
2. A nurse is assessing a client with a suspected pulmonary embolism. Which
finding is most consistent with this diagnosis?
A. Bradycardia
B. Hypertension
C. Sudden onset of dyspnea and pleuritic chest pain
D. Productive cough with green sputum
Rationale: Pulmonary embolism classically presents with sudden dyspnea,
pleuritic chest pain, and tachycardia. Bradycardia and hypertension are not
typical. Productive cough with green sputum suggests infection such as
pneumonia.
,3. A nurse is teaching a client about a low-purine diet. Which food should the
client avoid?
A. Apples
B. Rice
C. Sardines
D. Lettuce
Rationale: Sardines are high in purines and should be avoided by clients with
gout or those on a low-purine diet. Apples, rice, and lettuce are low in
purines.
4. A nurse is caring for a client in the immediate postoperative period
following a thyroidectomy. Which finding requires immediate intervention?
A. Pain at the incision site
B. Hoarseness of voice
C. Stridor and difficulty breathing
D. Serum calcium 9.0 mg/dL
Rationale: Stridor and difficulty breathing after thyroidectomy indicate
airway obstruction from hematoma or laryngeal edema, which is a life-
threatening emergency. Hoarseness may be expected from surgical
manipulation. Pain is expected. Serum calcium of 9.0 mg/dL is within normal
limits.
5. A nurse is reviewing laboratory results for a client with chronic kidney
disease. Which finding is expected?
A. Serum creatinine 0.8 mg/dL
B. BUN 10 mg/dL
C. Serum potassium 6.2 mEq/L
D. Hemoglobin 16 g/dL
Rationale: Hyperkalemia is common in chronic kidney disease due to
decreased potassium excretion. Elevated creatinine and BUN and anemia are
also expected. A hemoglobin of 16 g/dL is not expected; anemia is typical.
6. A nurse is administering furosemide to a client. Which laboratory value
should the nurse monitor most closely?
,A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Rationale: Furosemide is a loop diuretic that causes potassium loss, leading
to hypokalemia. Potassium should be monitored closely. While sodium,
calcium, and magnesium can also be affected, potassium is the priority.
7. A nurse is caring for a client with a new colostomy. Which statement by the
client indicates understanding of colostomy care?
A. "I will change the pouch every day."
B. "I will clean the skin around the stoma with warm water and pat it dry."
C. "I will use alcohol to clean the stoma."
D. "I will apply the new pouch before cleaning the skin."
Rationale: The skin around the stoma should be cleaned with warm water
and patted dry before applying a new pouch. The pouch is changed every 3 to
7 days, not daily. Alcohol is irritating to the stoma and skin. The pouch should
be applied after cleaning.
8. A nurse is assessing a client with increased intracranial pressure. Which
finding is an early sign of increased ICP?
A. Decerebrate posturing
B. Fixed and dilated pupils
C. Restlessness and confusion
D. Loss of consciousness
Rationale: Early signs of increased ICP include restlessness, confusion, and
changes in level of consciousness. Decerebrate posturing, fixed dilated pupils,
and loss of consciousness are late signs.
9. A nurse is preparing to administer heparin subcutaneously. Which action
should the nurse take?
A. Massage the injection site after administration
B. Use a 1-inch needle at a 90-degree angle
, C. Inject into the abdomen at least 2 inches from the umbilicus
D. Aspirate before injecting
Rationale: Heparin is injected into the abdomen at least 2 inches from the
umbilicus. The site should not be massaged. A short needle (3/8 to 5/8 inch)
is used at a 45- to 90-degree angle. Aspiration is not performed.
10. A nurse is caring for a client with bipolar disorder who is in the manic
phase. Which intervention is most appropriate?
A. Encourage group therapy sessions
B. Provide a stimulating environment
C. Provide a quiet, low-stimulation environment
D. Allow the client to make all decisions
Rationale: A quiet, low-stimulation environment reduces distractibility and
agitation in the manic client. Group therapy and stimulating environments
increase agitation. Allowing the client to make all decisions is unsafe during
mania.
11. A nurse is assessing a client with diabetes insipidus. Which finding is
expected?
A. Decreased urine output
B. Concentrated urine
C. Polyuria and polydipsia
D. Weight gain
Rationale: Diabetes insipidus is characterized by polyuria, polydipsia, and
dilute urine due to deficient antidiuretic hormone. Weight gain, concentrated
urine, and decreased urine output are not expected.
12. A nurse is caring for a client receiving total parenteral nutrition. Which
complication should the nurse monitor for?
A. Hypoglycemia
B. Hyperglycemia
C. Hypokalemia
D. Dehydration
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client who is receiving digoxin. Which assessment
finding indicates a therapeutic response to the medication?
A. Heart rate 110 bpm
B. Heart rate 76 bpm and regular
C. Urine output 20 mL/hr
D. Blood pressure 150/90 mm Hg
Rationale: Digoxin slows the heart rate and improves contractility. A heart
rate of 76 bpm and regular indicates a therapeutic response. A heart rate of
110 bpm indicates the medication is not effectively controlling the rate. Urine
output of 20 mL/hr is below the expected 30 mL/hr and indicates a problem.
Blood pressure of 150/90 mm Hg is elevated and not a direct indicator of
digoxin therapy.
2. A nurse is assessing a client with a suspected pulmonary embolism. Which
finding is most consistent with this diagnosis?
A. Bradycardia
B. Hypertension
C. Sudden onset of dyspnea and pleuritic chest pain
D. Productive cough with green sputum
Rationale: Pulmonary embolism classically presents with sudden dyspnea,
pleuritic chest pain, and tachycardia. Bradycardia and hypertension are not
typical. Productive cough with green sputum suggests infection such as
pneumonia.
,3. A nurse is teaching a client about a low-purine diet. Which food should the
client avoid?
A. Apples
B. Rice
C. Sardines
D. Lettuce
Rationale: Sardines are high in purines and should be avoided by clients with
gout or those on a low-purine diet. Apples, rice, and lettuce are low in
purines.
4. A nurse is caring for a client in the immediate postoperative period
following a thyroidectomy. Which finding requires immediate intervention?
A. Pain at the incision site
B. Hoarseness of voice
C. Stridor and difficulty breathing
D. Serum calcium 9.0 mg/dL
Rationale: Stridor and difficulty breathing after thyroidectomy indicate
airway obstruction from hematoma or laryngeal edema, which is a life-
threatening emergency. Hoarseness may be expected from surgical
manipulation. Pain is expected. Serum calcium of 9.0 mg/dL is within normal
limits.
5. A nurse is reviewing laboratory results for a client with chronic kidney
disease. Which finding is expected?
A. Serum creatinine 0.8 mg/dL
B. BUN 10 mg/dL
C. Serum potassium 6.2 mEq/L
D. Hemoglobin 16 g/dL
Rationale: Hyperkalemia is common in chronic kidney disease due to
decreased potassium excretion. Elevated creatinine and BUN and anemia are
also expected. A hemoglobin of 16 g/dL is not expected; anemia is typical.
6. A nurse is administering furosemide to a client. Which laboratory value
should the nurse monitor most closely?
,A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Rationale: Furosemide is a loop diuretic that causes potassium loss, leading
to hypokalemia. Potassium should be monitored closely. While sodium,
calcium, and magnesium can also be affected, potassium is the priority.
7. A nurse is caring for a client with a new colostomy. Which statement by the
client indicates understanding of colostomy care?
A. "I will change the pouch every day."
B. "I will clean the skin around the stoma with warm water and pat it dry."
C. "I will use alcohol to clean the stoma."
D. "I will apply the new pouch before cleaning the skin."
Rationale: The skin around the stoma should be cleaned with warm water
and patted dry before applying a new pouch. The pouch is changed every 3 to
7 days, not daily. Alcohol is irritating to the stoma and skin. The pouch should
be applied after cleaning.
8. A nurse is assessing a client with increased intracranial pressure. Which
finding is an early sign of increased ICP?
A. Decerebrate posturing
B. Fixed and dilated pupils
C. Restlessness and confusion
D. Loss of consciousness
Rationale: Early signs of increased ICP include restlessness, confusion, and
changes in level of consciousness. Decerebrate posturing, fixed dilated pupils,
and loss of consciousness are late signs.
9. A nurse is preparing to administer heparin subcutaneously. Which action
should the nurse take?
A. Massage the injection site after administration
B. Use a 1-inch needle at a 90-degree angle
, C. Inject into the abdomen at least 2 inches from the umbilicus
D. Aspirate before injecting
Rationale: Heparin is injected into the abdomen at least 2 inches from the
umbilicus. The site should not be massaged. A short needle (3/8 to 5/8 inch)
is used at a 45- to 90-degree angle. Aspiration is not performed.
10. A nurse is caring for a client with bipolar disorder who is in the manic
phase. Which intervention is most appropriate?
A. Encourage group therapy sessions
B. Provide a stimulating environment
C. Provide a quiet, low-stimulation environment
D. Allow the client to make all decisions
Rationale: A quiet, low-stimulation environment reduces distractibility and
agitation in the manic client. Group therapy and stimulating environments
increase agitation. Allowing the client to make all decisions is unsafe during
mania.
11. A nurse is assessing a client with diabetes insipidus. Which finding is
expected?
A. Decreased urine output
B. Concentrated urine
C. Polyuria and polydipsia
D. Weight gain
Rationale: Diabetes insipidus is characterized by polyuria, polydipsia, and
dilute urine due to deficient antidiuretic hormone. Weight gain, concentrated
urine, and decreased urine output are not expected.
12. A nurse is caring for a client receiving total parenteral nutrition. Which
complication should the nurse monitor for?
A. Hypoglycemia
B. Hyperglycemia
C. Hypokalemia
D. Dehydration
