NCLEX-RN Comprehensive Practice
Exam 005 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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1. The nurse is caring for a client who has just returned from
thyroidectomy. Which finding requires immediate intervention?
A. Mild incisional pain
B. Hoarse voice
C. Stridor
D. Difficulty swallowing
Answer: Stridor
Rationale: Stridor indicates upper-airway obstruction and may result from
laryngeal edema or injury to the recurrent laryngeal nerve. Immediate
airway assessment and intervention are required.
2. A client with heart failure is receiving furosemide. Which laboratory
value should the nurse monitor most closely?
A. Sodium
B. Potassium
C. Calcium
D. Hemoglobin
Answer: Potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium
loss. Hypokalemia increases the risk for dysrhythmias.
3. The nurse is assessing a client with suspected hypoglycemia. Which
finding is most consistent with this condition?
,A. Warm, dry skin
B. Bradycardia
C. Tremors and diaphoresis
D. Deep, rapid respirations
Answer: Tremors and diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system, causing
sweating, tremors, palpitations, anxiety, and hunger.
4. A client with chronic obstructive pulmonary disease is receiving oxygen.
Which oxygen saturation target is generally appropriate for a client at
risk for chronic carbon dioxide retention?
A. 100%
B. 98–100%
C. 94–98%
D. 88–92%
Answer: 88–92%
Rationale: Many clients with COPD and chronic hypercapnia are maintained
at approximately 88–92% oxygen saturation to provide adequate
oxygenation while reducing the risk of excessive oxygen administration.
5. A client taking warfarin has an international normalized ratio (INR) of 5.8.
Which action should the nurse anticipate?
A. Administer the next dose as scheduled
B. Hold warfarin and notify the provider
C. Administer aspirin
D. Encourage foods high in vitamin K immediately
Answer: Hold warfarin and notify the provider
Rationale: An INR of 5.8 represents excessive anticoagulation and increases
bleeding risk. Warfarin should generally be held and the provider notified for
further management.
6. Which assessment finding is most concerning in a client with increased
intracranial pressure?
,A. Headache
B. Nausea
C. Decreased level of consciousness
D. Photophobia
Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening neurologic function and increasing intracranial pressure.
7. A nurse is preparing to administer digoxin. The client's apical pulse is
52/min. What should the nurse do?
A. Administer the medication
B. Recheck the pulse after exercise
C. Hold the medication and notify the provider
D. Give the medication with food
Answer: Hold the medication and notify the provider
Rationale: Digoxin can cause or worsen bradycardia. The medication is
commonly withheld when the adult apical pulse is below 60/min, according
to prescribed parameters.
8. Which finding is characteristic of diabetic ketoacidosis?
A. Hypoglycemia
B. Metabolic alkalosis
C. Kussmaul respirations
D. Severe bradycardia
Answer: Kussmaul respirations
Rationale: Kussmaul respirations are deep and rapid respirations that
compensate for metabolic acidosis associated with diabetic ketoacidosis.
9. A client receiving a blood transfusion develops chills, fever, and back
pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
, C. Administer acetaminophen
D. Increase the infusion rate
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain may indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately and
appropriate emergency measures initiated.
10.Which client should the nurse assess first?
A. A client with pneumonia and a temperature of 38.2°C
B. A postoperative client reporting incisional pain
C. A client with asthma who has a silent chest
D. A client with diabetes requesting a snack
Answer: A client with asthma who has a silent chest
Rationale: A silent chest in severe asthma indicates minimal air movement
and potentially life-threatening airway obstruction.
11.A client receiving heparin develops a platelet count that decreases
significantly from baseline. Which complication should the nurse
suspect?
A. Disseminated intravascular coagulation
B. Heparin-induced thrombocytopenia
C. Iron-deficiency anemia
D. Pernicious anemia
Answer: Heparin-induced thrombocytopenia
Rationale: A significant platelet decline after heparin exposure may indicate
HIT, a serious immune-mediated complication associated with thrombosis.
12.Which intervention is appropriate for a client experiencing a seizure?
A. Insert a tongue blade
B. Restrain the extremities
C. Turn the client to the side
D. Place fingers inside the client's mouth
Answer: Turn the client to the side
Exam 005 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. The nurse is caring for a client who has just returned from
thyroidectomy. Which finding requires immediate intervention?
A. Mild incisional pain
B. Hoarse voice
C. Stridor
D. Difficulty swallowing
Answer: Stridor
Rationale: Stridor indicates upper-airway obstruction and may result from
laryngeal edema or injury to the recurrent laryngeal nerve. Immediate
airway assessment and intervention are required.
2. A client with heart failure is receiving furosemide. Which laboratory
value should the nurse monitor most closely?
A. Sodium
B. Potassium
C. Calcium
D. Hemoglobin
Answer: Potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium
loss. Hypokalemia increases the risk for dysrhythmias.
3. The nurse is assessing a client with suspected hypoglycemia. Which
finding is most consistent with this condition?
,A. Warm, dry skin
B. Bradycardia
C. Tremors and diaphoresis
D. Deep, rapid respirations
Answer: Tremors and diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system, causing
sweating, tremors, palpitations, anxiety, and hunger.
4. A client with chronic obstructive pulmonary disease is receiving oxygen.
Which oxygen saturation target is generally appropriate for a client at
risk for chronic carbon dioxide retention?
A. 100%
B. 98–100%
C. 94–98%
D. 88–92%
Answer: 88–92%
Rationale: Many clients with COPD and chronic hypercapnia are maintained
at approximately 88–92% oxygen saturation to provide adequate
oxygenation while reducing the risk of excessive oxygen administration.
5. A client taking warfarin has an international normalized ratio (INR) of 5.8.
Which action should the nurse anticipate?
A. Administer the next dose as scheduled
B. Hold warfarin and notify the provider
C. Administer aspirin
D. Encourage foods high in vitamin K immediately
Answer: Hold warfarin and notify the provider
Rationale: An INR of 5.8 represents excessive anticoagulation and increases
bleeding risk. Warfarin should generally be held and the provider notified for
further management.
6. Which assessment finding is most concerning in a client with increased
intracranial pressure?
,A. Headache
B. Nausea
C. Decreased level of consciousness
D. Photophobia
Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening neurologic function and increasing intracranial pressure.
7. A nurse is preparing to administer digoxin. The client's apical pulse is
52/min. What should the nurse do?
A. Administer the medication
B. Recheck the pulse after exercise
C. Hold the medication and notify the provider
D. Give the medication with food
Answer: Hold the medication and notify the provider
Rationale: Digoxin can cause or worsen bradycardia. The medication is
commonly withheld when the adult apical pulse is below 60/min, according
to prescribed parameters.
8. Which finding is characteristic of diabetic ketoacidosis?
A. Hypoglycemia
B. Metabolic alkalosis
C. Kussmaul respirations
D. Severe bradycardia
Answer: Kussmaul respirations
Rationale: Kussmaul respirations are deep and rapid respirations that
compensate for metabolic acidosis associated with diabetic ketoacidosis.
9. A client receiving a blood transfusion develops chills, fever, and back
pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
, C. Administer acetaminophen
D. Increase the infusion rate
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain may indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately and
appropriate emergency measures initiated.
10.Which client should the nurse assess first?
A. A client with pneumonia and a temperature of 38.2°C
B. A postoperative client reporting incisional pain
C. A client with asthma who has a silent chest
D. A client with diabetes requesting a snack
Answer: A client with asthma who has a silent chest
Rationale: A silent chest in severe asthma indicates minimal air movement
and potentially life-threatening airway obstruction.
11.A client receiving heparin develops a platelet count that decreases
significantly from baseline. Which complication should the nurse
suspect?
A. Disseminated intravascular coagulation
B. Heparin-induced thrombocytopenia
C. Iron-deficiency anemia
D. Pernicious anemia
Answer: Heparin-induced thrombocytopenia
Rationale: A significant platelet decline after heparin exposure may indicate
HIT, a serious immune-mediated complication associated with thrombosis.
12.Which intervention is appropriate for a client experiencing a seizure?
A. Insert a tongue blade
B. Restrain the extremities
C. Turn the client to the side
D. Place fingers inside the client's mouth
Answer: Turn the client to the side
