NCLEX-RN Comprehensive Practice
Exam 003 100 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 furosemide. Which of the
following findings should the nurse identify as an adverse effect of this
medication?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Rationale: Furosemide is a loop diuretic that causes potassium loss, leading
to hypokalemia. Clients should be monitored for low potassium levels and
may need potassium supplementation.
2. A nurse is assessing a client who has been diagnosed with major
depressive disorder. Which of the following findings should the nurse expect?
A. Anhedonia
B. Increased energy
C. Hyperactivity
D. Grandiosity
Rationale: Anhedonia, the inability to experience pleasure, is a hallmark
symptom of major depressive disorder. Other expected findings include
depressed mood, fatigue, and decreased energy.
3. A nurse is caring for a client who is in the immediate postoperative period
following a thyroidectomy. Which of the following findings should the nurse
report to the provider immediately?
,A. Hoarse voice
B. Laryngeal stridor
C. Sore throat
D. Serosanguineous drainage
Rationale: Laryngeal stridor indicates respiratory obstruction due to
laryngeal edema or nerve damage, which is a medical emergency requiring
immediate intervention.
4. A nurse is teaching a client who has a new prescription for warfarin. Which
of the following statements by the client indicates an understanding of the
teaching?
A. "I should increase my intake of green leafy vegetables."
B. "I should take aspirin for headaches."
C. "I should use a soft toothbrush."
D. "I should double my dose if I miss one."
Rationale: Warfarin increases bleeding risk, so clients should use a soft
toothbrush to prevent gum bleeding. Green leafy vegetables contain vitamin
K, which antagonizes warfarin.
5. A nurse is assessing a newborn immediately following delivery. Which of
the following findings should the nurse report immediately?
A. Heart rate of 140/min
B. Central cyanosis
C. Acrocyanosis
D. Respiratory rate of 40/min
Rationale: Central cyanosis (cyanosis of the trunk and mucous membranes)
indicates inadequate oxygenation and requires immediate intervention.
Acrocyanosis (bluish hands and feet) is a normal finding in newborns.
6. A nurse is caring for a client who has been prescribed lithium carbonate.
Which of the following findings indicates lithium toxicity?
A. Weight gain
B. Coarse hand tremors
, C. Increased appetite
D. Polyuria
Rationale: Coarse hand tremors are an early sign of lithium toxicity. Other
signs include vomiting, diarrhea, and confusion. Therapeutic lithium levels
range from 0.6 to 1.2 mEq/L.
7. A nurse is preparing to administer digoxin to a client. Which of the
following findings should the nurse report before administering the
medication?
A. Heart rate of 88/min
B. Heart rate of 52/min
C. Blood pressure of 120/80 mm Hg
D. Respiratory rate of 18/min
Rationale: Digoxin should be withheld if the apical pulse is below 60/min in
adults, as bradycardia is a sign of digoxin toxicity. The nurse should hold the
medication and notify the provider.
8. A nurse is caring for a client who is experiencing a panic attack. Which of
the following actions should the nurse take first?
A. Encourage the client to verbalize feelings
B. Stay with the client and remain calm
C. Administer an anti-anxiety medication
D. Move the client to a quiet area
Rationale: The priority nursing action during a panic attack is to stay with the
client and remain calm to provide safety and reassurance. This helps decrease
the client's anxiety.
9. A nurse is reviewing the laboratory results of a client who has diabetes
mellitus. Which of the following findings indicates poor glycemic control?
A. Fasting blood glucose of 95 mg/dL
B. Glycosylated hemoglobin (HbA1c) of 9%
C. Random blood glucose of 110 mg/dL
D. Postprandial blood glucose of 130 mg/dL
Exam 003 100 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 furosemide. Which of the
following findings should the nurse identify as an adverse effect of this
medication?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Rationale: Furosemide is a loop diuretic that causes potassium loss, leading
to hypokalemia. Clients should be monitored for low potassium levels and
may need potassium supplementation.
2. A nurse is assessing a client who has been diagnosed with major
depressive disorder. Which of the following findings should the nurse expect?
A. Anhedonia
B. Increased energy
C. Hyperactivity
D. Grandiosity
Rationale: Anhedonia, the inability to experience pleasure, is a hallmark
symptom of major depressive disorder. Other expected findings include
depressed mood, fatigue, and decreased energy.
3. A nurse is caring for a client who is in the immediate postoperative period
following a thyroidectomy. Which of the following findings should the nurse
report to the provider immediately?
,A. Hoarse voice
B. Laryngeal stridor
C. Sore throat
D. Serosanguineous drainage
Rationale: Laryngeal stridor indicates respiratory obstruction due to
laryngeal edema or nerve damage, which is a medical emergency requiring
immediate intervention.
4. A nurse is teaching a client who has a new prescription for warfarin. Which
of the following statements by the client indicates an understanding of the
teaching?
A. "I should increase my intake of green leafy vegetables."
B. "I should take aspirin for headaches."
C. "I should use a soft toothbrush."
D. "I should double my dose if I miss one."
Rationale: Warfarin increases bleeding risk, so clients should use a soft
toothbrush to prevent gum bleeding. Green leafy vegetables contain vitamin
K, which antagonizes warfarin.
5. A nurse is assessing a newborn immediately following delivery. Which of
the following findings should the nurse report immediately?
A. Heart rate of 140/min
B. Central cyanosis
C. Acrocyanosis
D. Respiratory rate of 40/min
Rationale: Central cyanosis (cyanosis of the trunk and mucous membranes)
indicates inadequate oxygenation and requires immediate intervention.
Acrocyanosis (bluish hands and feet) is a normal finding in newborns.
6. A nurse is caring for a client who has been prescribed lithium carbonate.
Which of the following findings indicates lithium toxicity?
A. Weight gain
B. Coarse hand tremors
, C. Increased appetite
D. Polyuria
Rationale: Coarse hand tremors are an early sign of lithium toxicity. Other
signs include vomiting, diarrhea, and confusion. Therapeutic lithium levels
range from 0.6 to 1.2 mEq/L.
7. A nurse is preparing to administer digoxin to a client. Which of the
following findings should the nurse report before administering the
medication?
A. Heart rate of 88/min
B. Heart rate of 52/min
C. Blood pressure of 120/80 mm Hg
D. Respiratory rate of 18/min
Rationale: Digoxin should be withheld if the apical pulse is below 60/min in
adults, as bradycardia is a sign of digoxin toxicity. The nurse should hold the
medication and notify the provider.
8. A nurse is caring for a client who is experiencing a panic attack. Which of
the following actions should the nurse take first?
A. Encourage the client to verbalize feelings
B. Stay with the client and remain calm
C. Administer an anti-anxiety medication
D. Move the client to a quiet area
Rationale: The priority nursing action during a panic attack is to stay with the
client and remain calm to provide safety and reassurance. This helps decrease
the client's anxiety.
9. A nurse is reviewing the laboratory results of a client who has diabetes
mellitus. Which of the following findings indicates poor glycemic control?
A. Fasting blood glucose of 95 mg/dL
B. Glycosylated hemoglobin (HbA1c) of 9%
C. Random blood glucose of 110 mg/dL
D. Postprandial blood glucose of 130 mg/dL
