NCLEX RN Adult Medical Surgical
Nursing Exam 2 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
1. A client with heart failure reports increasing shortness of breath and a
2kg (4.4-lb) weight gain over 3 days. Which finding requires the nurse’s
immediate attention?
A. Mild ankle edema
B. Fatigue after activity
C. Crackles throughout both lung fields
D. Increased urination after taking furosemide
Answer: Crackles throughout both lung fields
Rationale: Bilateral crackles indicate pulmonary fluid accumulation and
worsening pulmonary edema. This finding can rapidly compromise
oxygenation and requires prompt intervention.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which oxygen saturation goal is generally appropriate?
A. 70%–75%
B. 80%–84%
C. 88%–92%
D. 98%–100%
Answer: 88%–92%
Rationale: Clients with COPD who are at risk for chronic carbon dioxide
retention are commonly maintained at an oxygen saturation of
approximately 88%–92%, unless otherwise prescribed.
, 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 blood glucose level
C. Encourage the client to ambulate
D. Administer long-acting insulin
Answer: Check the blood glucose level
Rationale: The manifestations strongly suggest hypoglycemia. Blood glucose
should be checked promptly, and treatment should follow based on the result
and the client’s ability to swallow.
4. A client with a suspected stroke has difficulty speaking and facial
drooping. What is the nurse’s priority?
A. Give oral fluids
B. Place the client flat
C. Determine the time symptoms began
D. Administer an antacid
Answer: Determine the time symptoms began
Rationale: The exact time the client was last known well is critical when
determining eligibility for time-sensitive stroke therapies.
5. A client receiving a blood transfusion develops chills, fever, and low back
pain. What should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain a urine specimen
Answer: Stop the transfusion
Rationale: These findings may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the nurse should
maintain IV access with appropriate compatible solution per protocol.
, 6. A client with chronic kidney disease has a potassium level of 6.5 mEq/L.
Which ECG finding should the nurse anticipate?
A. Peaked T waves
B. ST elevation only
C. Shortened PR interval
D. Prominent U waves
Answer: Peaked T waves
Rationale: Hyperkalemia commonly causes tall, peaked T waves and may
progress to widening of the QRS complex and life-threatening dysrhythmias.
7. A client with pneumonia has a respiratory rate of 32/min, oxygen
saturation of 84%, and increasing confusion. Which action has the
highest priority?
A. Encourage oral fluids
B. Apply supplemental oxygen
C. Obtain a sputum culture
D. Administer an oral antibiotic
Answer: Apply supplemental oxygen
Rationale: Severe hypoxemia and altered mental status indicate impaired
oxygenation. Airway and breathing take priority over diagnostic and routine
interventions.
8. A client taking warfarin has an INR of 6.2 and no active bleeding. Which
prescription should the nurse anticipate?
A. Increase the warfarin dose
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 6.2 indicates excessive anticoagulation and increased
bleeding risk. Warfarin should generally be held, and the provider should be
notified for further management.
, 9. A client with a chest tube has continuous bubbling in the water-seal
chamber. What does this finding most likely indicate?
A. Normal lung re-expansion
B. An air leak
C. A blocked chest tube
D. Excessive fluid drainage
Answer: An air leak
Rationale: Continuous bubbling in the water-seal chamber usually indicates
an air leak in the system. The nurse should assess the tubing and connections
to locate the source.
10. A client with a gastrointestinal bleed has a blood pressure of 86/50 mm
Hg and heart rate of 124/min. Which finding is most concerning?
A. Mild nausea
B. Orthostatic dizziness
C. Hypotension with tachycardia
D. Dark stool
Answer: Hypotension with tachycardia
Rationale: Hypotension and tachycardia are signs of significant volume loss
and possible hypovolemic shock. Rapid assessment and fluid/blood
replacement may be required.
11. A client with a new tracheostomy becomes restless and develops noisy
respirations. What should the nurse do first?
A. Remove the tracheostomy tube
B. Assess the airway and suction if indicated
C. Offer oral fluids
D. Place the client in Trendelenburg position
Answer: Assess the airway and suction if indicated
Rationale: Restlessness and noisy breathing may indicate airway obstruction
from secretions. Airway assessment and appropriate suctioning are priority
interventions.
Nursing Exam 2 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
1. A client with heart failure reports increasing shortness of breath and a
2kg (4.4-lb) weight gain over 3 days. Which finding requires the nurse’s
immediate attention?
A. Mild ankle edema
B. Fatigue after activity
C. Crackles throughout both lung fields
D. Increased urination after taking furosemide
Answer: Crackles throughout both lung fields
Rationale: Bilateral crackles indicate pulmonary fluid accumulation and
worsening pulmonary edema. This finding can rapidly compromise
oxygenation and requires prompt intervention.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which oxygen saturation goal is generally appropriate?
A. 70%–75%
B. 80%–84%
C. 88%–92%
D. 98%–100%
Answer: 88%–92%
Rationale: Clients with COPD who are at risk for chronic carbon dioxide
retention are commonly maintained at an oxygen saturation of
approximately 88%–92%, unless otherwise prescribed.
, 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 blood glucose level
C. Encourage the client to ambulate
D. Administer long-acting insulin
Answer: Check the blood glucose level
Rationale: The manifestations strongly suggest hypoglycemia. Blood glucose
should be checked promptly, and treatment should follow based on the result
and the client’s ability to swallow.
4. A client with a suspected stroke has difficulty speaking and facial
drooping. What is the nurse’s priority?
A. Give oral fluids
B. Place the client flat
C. Determine the time symptoms began
D. Administer an antacid
Answer: Determine the time symptoms began
Rationale: The exact time the client was last known well is critical when
determining eligibility for time-sensitive stroke therapies.
5. A client receiving a blood transfusion develops chills, fever, and low back
pain. What should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain a urine specimen
Answer: Stop the transfusion
Rationale: These findings may indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the nurse should
maintain IV access with appropriate compatible solution per protocol.
, 6. A client with chronic kidney disease has a potassium level of 6.5 mEq/L.
Which ECG finding should the nurse anticipate?
A. Peaked T waves
B. ST elevation only
C. Shortened PR interval
D. Prominent U waves
Answer: Peaked T waves
Rationale: Hyperkalemia commonly causes tall, peaked T waves and may
progress to widening of the QRS complex and life-threatening dysrhythmias.
7. A client with pneumonia has a respiratory rate of 32/min, oxygen
saturation of 84%, and increasing confusion. Which action has the
highest priority?
A. Encourage oral fluids
B. Apply supplemental oxygen
C. Obtain a sputum culture
D. Administer an oral antibiotic
Answer: Apply supplemental oxygen
Rationale: Severe hypoxemia and altered mental status indicate impaired
oxygenation. Airway and breathing take priority over diagnostic and routine
interventions.
8. A client taking warfarin has an INR of 6.2 and no active bleeding. Which
prescription should the nurse anticipate?
A. Increase the warfarin dose
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 6.2 indicates excessive anticoagulation and increased
bleeding risk. Warfarin should generally be held, and the provider should be
notified for further management.
, 9. A client with a chest tube has continuous bubbling in the water-seal
chamber. What does this finding most likely indicate?
A. Normal lung re-expansion
B. An air leak
C. A blocked chest tube
D. Excessive fluid drainage
Answer: An air leak
Rationale: Continuous bubbling in the water-seal chamber usually indicates
an air leak in the system. The nurse should assess the tubing and connections
to locate the source.
10. A client with a gastrointestinal bleed has a blood pressure of 86/50 mm
Hg and heart rate of 124/min. Which finding is most concerning?
A. Mild nausea
B. Orthostatic dizziness
C. Hypotension with tachycardia
D. Dark stool
Answer: Hypotension with tachycardia
Rationale: Hypotension and tachycardia are signs of significant volume loss
and possible hypovolemic shock. Rapid assessment and fluid/blood
replacement may be required.
11. A client with a new tracheostomy becomes restless and develops noisy
respirations. What should the nurse do first?
A. Remove the tracheostomy tube
B. Assess the airway and suction if indicated
C. Offer oral fluids
D. Place the client in Trendelenburg position
Answer: Assess the airway and suction if indicated
Rationale: Restlessness and noisy breathing may indicate airway obstruction
from secretions. Airway assessment and appropriate suctioning are priority
interventions.
