NCLEX-RN Comprehensive Practice
Exam 008 100 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 heart failure who reports increasing
shortness of breath. Which finding requires immediate intervention?
A. 1+ bilateral ankle edema
B. Respiratory rate of 24/min
C. Pink, frothy sputum
D. Fatigue after ambulation
Answer: Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema, which can
rapidly compromise oxygenation and requires immediate intervention.
2. A client receiving digoxin has an apical pulse of 52/min. What should the
nurse do?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Give the medication with food
D. Recheck the pulse after ambulation
Answer: Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. An apical pulse below 60/min in an adult
generally warrants withholding the dose and notifying the provider.
3. A client with diabetes mellitus is confused, diaphoretic, and trembling.
Which action should the nurse take first?
,A. Administer regular insulin
B. Check the client's blood glucose
C. Encourage exercise
D. Restrict oral fluids
Answer: Check the client's blood glucose
Rationale: The symptoms suggest hypoglycemia. Blood glucose should be assessed
immediately to confirm the condition and guide treatment.
4. 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
intracranial pressure and possible cerebral deterioration.
5. A nurse is teaching a client taking warfarin. Which statement indicates
correct understanding?
A. "I should avoid all foods containing vitamin K."
B. "I should keep my intake of vitamin K-containing foods consistent."
C. "I can take aspirin whenever I have a headache."
D. "I do not need blood tests while taking this medication."
Answer: I should keep my intake of vitamin K-containing foods consistent.
Rationale: Vitamin K affects warfarin activity. Clients should maintain a consistent intake
rather than completely avoiding vitamin K-rich foods.
6. Which intervention is most appropriate for a client experiencing an acute
asthma exacerbation?
A. Encourage vigorous exercise
B. Administer the prescribed short-acting bronchodilator
C. Place the client supine
D. Restrict oxygen administration
,Answer: Administer the prescribed short-acting bronchodilator
Rationale: Short-acting bronchodilators such as albuterol rapidly relax bronchial smooth
muscle and are commonly used for acute asthma symptoms.
7. A client with chronic kidney disease has a potassium level of 6.4 mEq/L.
Which finding is the priority?
A. Muscle weakness
B. Nausea
C. Peaked T waves on ECG
D. Fatigue
Answer: Peaked T waves on ECG
Rationale: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias. Peaked T
waves are an important ECG manifestation requiring immediate attention.
8. Which prescription should the nurse question for a client with severe renal
impairment?
A. Acetaminophen
B. Sodium bicarbonate
C. Magnesium-containing antacid
D. Oral glucose
Answer: Magnesium-containing antacid
Rationale: Magnesium can accumulate in renal impairment and cause hypermagnesemia.
Magnesium-containing medications should be used cautiously in clients with kidney
dysfunction.
9. A client with pneumonia has a temperature of 39°C (102.2°F), respiratory
rate of 30/min, and oxygen saturation of 88%. Which intervention is the
priority?
A. Encourage oral fluids
B. Administer supplemental oxygen
C. Provide a high-protein meal
D. Encourage ambulation
Answer: Administer supplemental oxygen
, Rationale: The oxygen saturation of 88% indicates hypoxemia. Supporting oxygenation
takes priority over other interventions.
10. Which client should the nurse assess first?
A. Client with chronic arthritis reporting pain of 6/10
B. Client with COPD and oxygen saturation of 91% at baseline
C. Client with sudden unilateral weakness and slurred speech
D. Client requesting assistance with bathing
Answer: Client with sudden unilateral weakness and slurred speech
Rationale: Sudden neurological deficits suggest an acute stroke. Rapid assessment and
intervention are essential to reduce permanent neurological injury.
11. A client taking furosemide is at greatest risk for which electrolyte
imbalance?
A. Hypercalcemia
B. Hypokalemia
C. Hypermagnesemia
D. Hypernatremia
Answer: Hypokalemia
Rationale: Loop diuretics increase urinary potassium excretion and can cause
hypokalemia.
12. 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 another unit
D. Reassure the client that this is expected
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately.
Exam 008 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client with heart failure who reports increasing
shortness of breath. Which finding requires immediate intervention?
A. 1+ bilateral ankle edema
B. Respiratory rate of 24/min
C. Pink, frothy sputum
D. Fatigue after ambulation
Answer: Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema, which can
rapidly compromise oxygenation and requires immediate intervention.
2. A client receiving digoxin has an apical pulse of 52/min. What should the
nurse do?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Give the medication with food
D. Recheck the pulse after ambulation
Answer: Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. An apical pulse below 60/min in an adult
generally warrants withholding the dose and notifying the provider.
3. A client with diabetes mellitus is confused, diaphoretic, and trembling.
Which action should the nurse take first?
,A. Administer regular insulin
B. Check the client's blood glucose
C. Encourage exercise
D. Restrict oral fluids
Answer: Check the client's blood glucose
Rationale: The symptoms suggest hypoglycemia. Blood glucose should be assessed
immediately to confirm the condition and guide treatment.
4. 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
intracranial pressure and possible cerebral deterioration.
5. A nurse is teaching a client taking warfarin. Which statement indicates
correct understanding?
A. "I should avoid all foods containing vitamin K."
B. "I should keep my intake of vitamin K-containing foods consistent."
C. "I can take aspirin whenever I have a headache."
D. "I do not need blood tests while taking this medication."
Answer: I should keep my intake of vitamin K-containing foods consistent.
Rationale: Vitamin K affects warfarin activity. Clients should maintain a consistent intake
rather than completely avoiding vitamin K-rich foods.
6. Which intervention is most appropriate for a client experiencing an acute
asthma exacerbation?
A. Encourage vigorous exercise
B. Administer the prescribed short-acting bronchodilator
C. Place the client supine
D. Restrict oxygen administration
,Answer: Administer the prescribed short-acting bronchodilator
Rationale: Short-acting bronchodilators such as albuterol rapidly relax bronchial smooth
muscle and are commonly used for acute asthma symptoms.
7. A client with chronic kidney disease has a potassium level of 6.4 mEq/L.
Which finding is the priority?
A. Muscle weakness
B. Nausea
C. Peaked T waves on ECG
D. Fatigue
Answer: Peaked T waves on ECG
Rationale: Severe hyperkalemia can cause life-threatening cardiac dysrhythmias. Peaked T
waves are an important ECG manifestation requiring immediate attention.
8. Which prescription should the nurse question for a client with severe renal
impairment?
A. Acetaminophen
B. Sodium bicarbonate
C. Magnesium-containing antacid
D. Oral glucose
Answer: Magnesium-containing antacid
Rationale: Magnesium can accumulate in renal impairment and cause hypermagnesemia.
Magnesium-containing medications should be used cautiously in clients with kidney
dysfunction.
9. A client with pneumonia has a temperature of 39°C (102.2°F), respiratory
rate of 30/min, and oxygen saturation of 88%. Which intervention is the
priority?
A. Encourage oral fluids
B. Administer supplemental oxygen
C. Provide a high-protein meal
D. Encourage ambulation
Answer: Administer supplemental oxygen
, Rationale: The oxygen saturation of 88% indicates hypoxemia. Supporting oxygenation
takes priority over other interventions.
10. Which client should the nurse assess first?
A. Client with chronic arthritis reporting pain of 6/10
B. Client with COPD and oxygen saturation of 91% at baseline
C. Client with sudden unilateral weakness and slurred speech
D. Client requesting assistance with bathing
Answer: Client with sudden unilateral weakness and slurred speech
Rationale: Sudden neurological deficits suggest an acute stroke. Rapid assessment and
intervention are essential to reduce permanent neurological injury.
11. A client taking furosemide is at greatest risk for which electrolyte
imbalance?
A. Hypercalcemia
B. Hypokalemia
C. Hypermagnesemia
D. Hypernatremia
Answer: Hypokalemia
Rationale: Loop diuretics increase urinary potassium excretion and can cause
hypokalemia.
12. 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 another unit
D. Reassure the client that this is expected
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately.
