NCLEX-RN Comprehensive Practice
Exam 009 100 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 pulmonary edema. Which
assessment finding requires immediate intervention?
A. Bilateral crackles
B. Pink, frothy sputum
C. Oxygen saturation of 82%
D. Respiratory rate of 28/min
Answer: Oxygen saturation of 82%
Rationale: An oxygen saturation of 82% indicates severe hypoxemia and
requires immediate intervention to improve oxygenation.
2. A client taking warfarin has an INR of 5.8. What should the nurse do first?
A. Administer the prescribed warfarin
B. Encourage foods high in vitamin K
C. Hold the warfarin and notify the provider
D. Administer aspirin
Answer: Hold the warfarin and notify the provider
Rationale: An INR of 5.8 indicates excessive anticoagulation and an increased
risk of bleeding. The medication should be held and the provider notified.
,3. Which finding is most characteristic of hypoglycemia?
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,
producing sweating, tremors, palpitations, anxiety, and hunger.
4. A client with COPD is receiving oxygen. Which oxygen saturation is
generally an appropriate target?
A. 100%
B. 98–100%
C. 88–92%
D. 70–75%
Answer: 88–92%
Rationale: Many clients with COPD and chronic carbon dioxide retention are
maintained at approximately 88–92% oxygen saturation to provide adequate
oxygenation while avoiding excessive oxygen administration.
5. A nurse is assessing a client with increased intracranial pressure. Which
finding is most concerning?
A. Headache
B. Nausea
C. Unequal pupils
D. Mild dizziness
Answer: Unequal pupils
Rationale: Unequal or dilated pupils may indicate brain herniation or
worsening neurologic compromise and require immediate intervention.
,6. A client with heart failure is prescribed furosemide. Which laboratory value
is most important for the nurse to monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelets
Answer: Potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium
loss, increasing the risk of dysrhythmias.
7. Which statement by a client taking nitroglycerin indicates correct
understanding?
A. “I should swallow the tablet with water.”
B. “I should take it only after severe chest pain develops.”
C. “I should sit down before taking the medication.”
D. “I can take unlimited doses if the pain continues.”
Answer: I should sit down before taking the medication.
Rationale: Nitroglycerin can cause hypotension and dizziness. Sitting or lying
down before administration reduces the risk of injury from falls.
8. A nurse is caring for a client with suspected sepsis. Which finding requires
the most immediate attention?
A. Temperature of 38.1°C (100.6°F)
B. Heart rate of 104/min
C. Blood pressure of 82/48 mm Hg
D. White blood cell count of 15,000/mm³
Answer: Blood pressure of 82/48 mm Hg
, Rationale: Severe hypotension suggests septic shock and inadequate tissue
perfusion, making immediate stabilization the priority.
9. Which intervention is appropriate for a client experiencing a tonic-clonic
seizure?
A. Insert a tongue blade
B. Restrain the extremities
C. Place the client on the side
D. Give oral fluids
Answer: Place the client on the side
Rationale: Side-lying positioning helps maintain airway patency and allows
secretions to drain, reducing aspiration risk.
10. A client receiving a blood transfusion develops chills, fever, and low back
pain. What is the nurse’s priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Recheck the temperature in 30 minutes
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain may indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately.
11. Which client should the nurse assess first?
A. A client with pneumonia reporting fatigue
B. A client with asthma who has difficulty speaking in full sentences
C. A client with diabetes requesting a snack
D. A client with arthritis reporting chronic pain
Answer: A client with asthma who has difficulty speaking in full sentences
Exam 009 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client with acute pulmonary edema. Which
assessment finding requires immediate intervention?
A. Bilateral crackles
B. Pink, frothy sputum
C. Oxygen saturation of 82%
D. Respiratory rate of 28/min
Answer: Oxygen saturation of 82%
Rationale: An oxygen saturation of 82% indicates severe hypoxemia and
requires immediate intervention to improve oxygenation.
2. A client taking warfarin has an INR of 5.8. What should the nurse do first?
A. Administer the prescribed warfarin
B. Encourage foods high in vitamin K
C. Hold the warfarin and notify the provider
D. Administer aspirin
Answer: Hold the warfarin and notify the provider
Rationale: An INR of 5.8 indicates excessive anticoagulation and an increased
risk of bleeding. The medication should be held and the provider notified.
,3. Which finding is most characteristic of hypoglycemia?
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,
producing sweating, tremors, palpitations, anxiety, and hunger.
4. A client with COPD is receiving oxygen. Which oxygen saturation is
generally an appropriate target?
A. 100%
B. 98–100%
C. 88–92%
D. 70–75%
Answer: 88–92%
Rationale: Many clients with COPD and chronic carbon dioxide retention are
maintained at approximately 88–92% oxygen saturation to provide adequate
oxygenation while avoiding excessive oxygen administration.
5. A nurse is assessing a client with increased intracranial pressure. Which
finding is most concerning?
A. Headache
B. Nausea
C. Unequal pupils
D. Mild dizziness
Answer: Unequal pupils
Rationale: Unequal or dilated pupils may indicate brain herniation or
worsening neurologic compromise and require immediate intervention.
,6. A client with heart failure is prescribed furosemide. Which laboratory value
is most important for the nurse to monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelets
Answer: Potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium
loss, increasing the risk of dysrhythmias.
7. Which statement by a client taking nitroglycerin indicates correct
understanding?
A. “I should swallow the tablet with water.”
B. “I should take it only after severe chest pain develops.”
C. “I should sit down before taking the medication.”
D. “I can take unlimited doses if the pain continues.”
Answer: I should sit down before taking the medication.
Rationale: Nitroglycerin can cause hypotension and dizziness. Sitting or lying
down before administration reduces the risk of injury from falls.
8. A nurse is caring for a client with suspected sepsis. Which finding requires
the most immediate attention?
A. Temperature of 38.1°C (100.6°F)
B. Heart rate of 104/min
C. Blood pressure of 82/48 mm Hg
D. White blood cell count of 15,000/mm³
Answer: Blood pressure of 82/48 mm Hg
, Rationale: Severe hypotension suggests septic shock and inadequate tissue
perfusion, making immediate stabilization the priority.
9. Which intervention is appropriate for a client experiencing a tonic-clonic
seizure?
A. Insert a tongue blade
B. Restrain the extremities
C. Place the client on the side
D. Give oral fluids
Answer: Place the client on the side
Rationale: Side-lying positioning helps maintain airway patency and allows
secretions to drain, reducing aspiration risk.
10. A client receiving a blood transfusion develops chills, fever, and low back
pain. What is the nurse’s priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Recheck the temperature in 30 minutes
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain may indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately.
11. Which client should the nurse assess first?
A. A client with pneumonia reporting fatigue
B. A client with asthma who has difficulty speaking in full sentences
C. A client with diabetes requesting a snack
D. A client with arthritis reporting chronic pain
Answer: A client with asthma who has difficulty speaking in full sentences
