NCLEX-RN Comprehensive Practice
Exam 002 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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1. A nurse is caring for a client with acute heart failure who is experiencing
severe dyspnea and pulmonary crackles. Which action should the nurse
take first?
A. Encourage oral fluids
B. Place the client in high-Fowler's position
C. Obtain the client's daily weight
D. Administer a prescribed stool softener
Answer: B. Place the client in high-Fowler's position
Rationale: Positioning the client upright improves lung expansion and
decreases venous return, which can reduce pulmonary congestion and
improve oxygenation.
2. A client receiving digoxin reports nausea and seeing yellow halos around
lights. Which action should the nurse take?
A. Administer the next dose with food
B. Encourage increased potassium intake
C. Hold the medication and notify the provider
D. Reassure the client that these effects are expected
Answer: C. Hold the medication and notify the provider
,Rationale: Nausea, visual disturbances, and dysrhythmias are manifestations
of digoxin toxicity. The medication should be withheld and the provider
notified.
3. A nurse is assessing a client with hypoglycemia. Which finding should the
nurse expect?
A. Warm, dry skin
B. Bradycardia
C. Tremors and diaphoresis
D. Kussmaul respirations
Answer: C. Tremors and diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system, causing
tremors, sweating, palpitations, anxiety, and hunger.
4. A client with COPD is receiving oxygen therapy. Which oxygen delivery
method is most appropriate for precise oxygen concentration?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Face tent
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise, controlled oxygen concentration
and is particularly useful for clients with COPD who may be sensitive to
excessive oxygen.
5. A client is prescribed warfarin. Which laboratory test should the nurse
monitor?
A. aPTT
B. INR
C. Troponin
D. Serum amylase
Answer: B. INR
,Rationale: The international normalized ratio (INR) is used to monitor the
therapeutic effect of warfarin and guide dosage adjustments.
6. A nurse is caring for a client who has a potassium level of 2.8 mEq/L (2.8
mmol/L). Which finding is most concerning?
A. Muscle weakness
B. Constipation
C. Cardiac dysrhythmia
D. Increased thirst
Answer: C. Cardiac dysrhythmia
Rationale: Significant hypokalemia can cause potentially life-threatening
cardiac dysrhythmias and requires prompt intervention.
7. A client with suspected bacterial meningitis is admitted. Which
precaution should the nurse initiate?
A. Contact precautions
B. Airborne precautions
C. Droplet precautions
D. Protective isolation
Answer: C. Droplet precautions
Rationale: Bacterial meningitis caused by organisms such as Neisseria
meningitidis requires droplet precautions, especially during the initial period
of treatment.
8. A nurse is caring for a client with a chest tube connected to a water-seal
drainage system. Which finding requires immediate intervention?
A. Tidaling in the water-seal chamber
B. Small amount of drainage
C. Continuous bubbling in the water-seal chamber
D. Mild discomfort at the insertion site
Answer: C. Continuous bubbling in the water-seal chamber
Rationale: Continuous bubbling usually indicates an air leak in the system and
requires assessment to identify and correct the source.
, 9. Which client should the nurse assess first?
A. A client with a blood glucose of 110 mg/dL
B. A postoperative client reporting incisional pain of 6/10
C. A client with asthma who has a silent chest
D. A client requesting assistance with bathing
Answer: C. A client with asthma who has a silent chest
Rationale: A silent chest in a client with severe asthma indicates minimal or
absent air movement and possible impending respiratory failure.
10.A client with diabetes mellitus is prescribed insulin lispro. When should
the nurse administer it?
A. At bedtime
B. 30 minutes before meals
C. When the meal tray is available
D. Two hours after the meal
Answer: C. When the meal tray is available
Rationale: Insulin lispro is rapid acting and should be administered close to
mealtime to reduce the risk of hypoglycemia.
11.A nurse is caring for a client with increased intracranial pressure. Which
intervention is appropriate?
A. Keep the neck flexed
B. Place the client flat
C. Elevate the head of the bed approximately 30 degrees
D. Encourage frequent coughing
Answer: C. Elevate the head of the bed approximately 30 degrees
Rationale: Elevating the head promotes venous drainage from the brain and
can help decrease intracranial pressure.
12.A client with Addison disease is at risk for which electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
Exam 002 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client with acute heart failure who is experiencing
severe dyspnea and pulmonary crackles. Which action should the nurse
take first?
A. Encourage oral fluids
B. Place the client in high-Fowler's position
C. Obtain the client's daily weight
D. Administer a prescribed stool softener
Answer: B. Place the client in high-Fowler's position
Rationale: Positioning the client upright improves lung expansion and
decreases venous return, which can reduce pulmonary congestion and
improve oxygenation.
2. A client receiving digoxin reports nausea and seeing yellow halos around
lights. Which action should the nurse take?
A. Administer the next dose with food
B. Encourage increased potassium intake
C. Hold the medication and notify the provider
D. Reassure the client that these effects are expected
Answer: C. Hold the medication and notify the provider
,Rationale: Nausea, visual disturbances, and dysrhythmias are manifestations
of digoxin toxicity. The medication should be withheld and the provider
notified.
3. A nurse is assessing a client with hypoglycemia. Which finding should the
nurse expect?
A. Warm, dry skin
B. Bradycardia
C. Tremors and diaphoresis
D. Kussmaul respirations
Answer: C. Tremors and diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system, causing
tremors, sweating, palpitations, anxiety, and hunger.
4. A client with COPD is receiving oxygen therapy. Which oxygen delivery
method is most appropriate for precise oxygen concentration?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Face tent
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise, controlled oxygen concentration
and is particularly useful for clients with COPD who may be sensitive to
excessive oxygen.
5. A client is prescribed warfarin. Which laboratory test should the nurse
monitor?
A. aPTT
B. INR
C. Troponin
D. Serum amylase
Answer: B. INR
,Rationale: The international normalized ratio (INR) is used to monitor the
therapeutic effect of warfarin and guide dosage adjustments.
6. A nurse is caring for a client who has a potassium level of 2.8 mEq/L (2.8
mmol/L). Which finding is most concerning?
A. Muscle weakness
B. Constipation
C. Cardiac dysrhythmia
D. Increased thirst
Answer: C. Cardiac dysrhythmia
Rationale: Significant hypokalemia can cause potentially life-threatening
cardiac dysrhythmias and requires prompt intervention.
7. A client with suspected bacterial meningitis is admitted. Which
precaution should the nurse initiate?
A. Contact precautions
B. Airborne precautions
C. Droplet precautions
D. Protective isolation
Answer: C. Droplet precautions
Rationale: Bacterial meningitis caused by organisms such as Neisseria
meningitidis requires droplet precautions, especially during the initial period
of treatment.
8. A nurse is caring for a client with a chest tube connected to a water-seal
drainage system. Which finding requires immediate intervention?
A. Tidaling in the water-seal chamber
B. Small amount of drainage
C. Continuous bubbling in the water-seal chamber
D. Mild discomfort at the insertion site
Answer: C. Continuous bubbling in the water-seal chamber
Rationale: Continuous bubbling usually indicates an air leak in the system and
requires assessment to identify and correct the source.
, 9. Which client should the nurse assess first?
A. A client with a blood glucose of 110 mg/dL
B. A postoperative client reporting incisional pain of 6/10
C. A client with asthma who has a silent chest
D. A client requesting assistance with bathing
Answer: C. A client with asthma who has a silent chest
Rationale: A silent chest in a client with severe asthma indicates minimal or
absent air movement and possible impending respiratory failure.
10.A client with diabetes mellitus is prescribed insulin lispro. When should
the nurse administer it?
A. At bedtime
B. 30 minutes before meals
C. When the meal tray is available
D. Two hours after the meal
Answer: C. When the meal tray is available
Rationale: Insulin lispro is rapid acting and should be administered close to
mealtime to reduce the risk of hypoglycemia.
11.A nurse is caring for a client with increased intracranial pressure. Which
intervention is appropriate?
A. Keep the neck flexed
B. Place the client flat
C. Elevate the head of the bed approximately 30 degrees
D. Encourage frequent coughing
Answer: C. Elevate the head of the bed approximately 30 degrees
Rationale: Elevating the head promotes venous drainage from the brain and
can help decrease intracranial pressure.
12.A client with Addison disease is at risk for which electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
