NCLEX RN Adult Medical Surgical
Nursing Exam 3 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
Question 1
A client with heart failure is receiving IV furosemide. Which finding requires the
nurse's immediate attention?
A. Urine output of 1,500 mL in 24 hours
B. Potassium level of 2.8 mEq/L
C. Blood pressure of 108/64 mm Hg
D. Weight loss of 1 kg over 24 hours
Answer: Potassium level of 2.8 mEq/L
Rationale: Severe hypokalemia can cause life-threatening cardiac
dysrhythmias. Furosemide increases potassium excretion, so a potassium
level of 2.8 mEq/L requires prompt intervention.
Question 2
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen.
Which oxygen saturation is generally an appropriate target for a client with
chronic CO₂ retention?
A. 100%
B. 98–100%
C. 94–98%
D. 88–92%
Answer: 88–92%
,Rationale: Clients with chronic CO₂ retention are commonly maintained at an
oxygen saturation of approximately 88–92% to provide adequate
oxygenation while avoiding excessive oxygen administration.
Question 3
A client with diabetes mellitus is awake, diaphoretic, and confused. The blood
glucose level is 48 mg/dL. What should the nurse do first?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Administer glucagon intramuscularly
D. Recheck the glucose in 1 hour
Answer: Give 15 g of rapid-acting carbohydrate
Rationale: An alert client who can safely swallow and has symptomatic
hypoglycemia should receive approximately 15 g of rapid-acting
carbohydrate, followed by reassessment of the glucose level.
Question 4
A client with suspected pulmonary embolism suddenly develops dyspnea and
chest pain. What is the nurse's priority action?
A. Encourage ambulation
B. Place the client in high-Fowler's position and administer oxygen
C. Give oral fluids
D. Place the client flat in bed
Answer: Place the client in high-Fowler's position and administer oxygen
Rationale: Airway and breathing are the immediate priorities. Positioning
upright improves ventilation, while oxygen helps correct hypoxemia.
Question 5
A client taking warfarin has an INR of 5.8 and reports bleeding gums. Which
action is most appropriate?
,A. Administer the next dose of warfarin
B. Hold warfarin and notify the provider
C. Encourage foods high in vitamin K immediately
D. Administer aspirin
Answer: Hold warfarin and notify the provider
Rationale: An INR of 5.8 with active bleeding indicates excessive
anticoagulation. Warfarin should be withheld and the provider notified for
further management.
Question 6
A client with SIADH has a sodium level of 118 mEq/L. Which intervention
should the nurse anticipate?
A. Encourage large amounts of free water
B. Restrict fluid intake
C. Administer hypotonic IV fluids
D. Encourage a low-sodium diet
Answer: Restrict fluid intake
Rationale: SIADH causes excessive water retention and dilutional
hyponatremia. Fluid restriction is a primary treatment to reduce water excess
and improve sodium concentration.
Question 7
A client with Addison disease develops severe weakness, hypotension,
vomiting, and confusion. Which complication should the nurse suspect?
A. Thyroid storm
B. Addisonian crisis
C. Cushing syndrome
D. Hyperosmolar hyperglycemic state
, Answer: Addisonian crisis
Rationale: Addisonian crisis is an acute adrenal insufficiency characterized by
profound hypotension, weakness, gastrointestinal symptoms, electrolyte
abnormalities, and potentially shock.
Question 8
Which finding in a client with increased intracranial pressure requires
immediate intervention?
A. Headache
B. Restlessness
C. Uneilateral dilated pupil
D. Mild nausea
Answer: Unilateral dilated pupil
Rationale: A newly dilated or nonreactive pupil may indicate brain herniation
or cranial nerve compression and requires immediate intervention.
Question 9
A client with a chest tube has continuous bubbling in the water-seal chamber.
What should the nurse suspect?
A. Normal functioning
B. An air leak
C. Fluid overload
D. Lung re-expansion
Answer: An air leak
Rationale: Continuous bubbling in the water-seal chamber usually indicates
an air leak somewhere in the system. The nurse should assess the tubing and
connections.
Nursing Exam 3 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
Question 1
A client with heart failure is receiving IV furosemide. Which finding requires the
nurse's immediate attention?
A. Urine output of 1,500 mL in 24 hours
B. Potassium level of 2.8 mEq/L
C. Blood pressure of 108/64 mm Hg
D. Weight loss of 1 kg over 24 hours
Answer: Potassium level of 2.8 mEq/L
Rationale: Severe hypokalemia can cause life-threatening cardiac
dysrhythmias. Furosemide increases potassium excretion, so a potassium
level of 2.8 mEq/L requires prompt intervention.
Question 2
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen.
Which oxygen saturation is generally an appropriate target for a client with
chronic CO₂ retention?
A. 100%
B. 98–100%
C. 94–98%
D. 88–92%
Answer: 88–92%
,Rationale: Clients with chronic CO₂ retention are commonly maintained at an
oxygen saturation of approximately 88–92% to provide adequate
oxygenation while avoiding excessive oxygen administration.
Question 3
A client with diabetes mellitus is awake, diaphoretic, and confused. The blood
glucose level is 48 mg/dL. What should the nurse do first?
A. Administer regular insulin
B. Give 15 g of rapid-acting carbohydrate
C. Administer glucagon intramuscularly
D. Recheck the glucose in 1 hour
Answer: Give 15 g of rapid-acting carbohydrate
Rationale: An alert client who can safely swallow and has symptomatic
hypoglycemia should receive approximately 15 g of rapid-acting
carbohydrate, followed by reassessment of the glucose level.
Question 4
A client with suspected pulmonary embolism suddenly develops dyspnea and
chest pain. What is the nurse's priority action?
A. Encourage ambulation
B. Place the client in high-Fowler's position and administer oxygen
C. Give oral fluids
D. Place the client flat in bed
Answer: Place the client in high-Fowler's position and administer oxygen
Rationale: Airway and breathing are the immediate priorities. Positioning
upright improves ventilation, while oxygen helps correct hypoxemia.
Question 5
A client taking warfarin has an INR of 5.8 and reports bleeding gums. Which
action is most appropriate?
,A. Administer the next dose of warfarin
B. Hold warfarin and notify the provider
C. Encourage foods high in vitamin K immediately
D. Administer aspirin
Answer: Hold warfarin and notify the provider
Rationale: An INR of 5.8 with active bleeding indicates excessive
anticoagulation. Warfarin should be withheld and the provider notified for
further management.
Question 6
A client with SIADH has a sodium level of 118 mEq/L. Which intervention
should the nurse anticipate?
A. Encourage large amounts of free water
B. Restrict fluid intake
C. Administer hypotonic IV fluids
D. Encourage a low-sodium diet
Answer: Restrict fluid intake
Rationale: SIADH causes excessive water retention and dilutional
hyponatremia. Fluid restriction is a primary treatment to reduce water excess
and improve sodium concentration.
Question 7
A client with Addison disease develops severe weakness, hypotension,
vomiting, and confusion. Which complication should the nurse suspect?
A. Thyroid storm
B. Addisonian crisis
C. Cushing syndrome
D. Hyperosmolar hyperglycemic state
, Answer: Addisonian crisis
Rationale: Addisonian crisis is an acute adrenal insufficiency characterized by
profound hypotension, weakness, gastrointestinal symptoms, electrolyte
abnormalities, and potentially shock.
Question 8
Which finding in a client with increased intracranial pressure requires
immediate intervention?
A. Headache
B. Restlessness
C. Uneilateral dilated pupil
D. Mild nausea
Answer: Unilateral dilated pupil
Rationale: A newly dilated or nonreactive pupil may indicate brain herniation
or cranial nerve compression and requires immediate intervention.
Question 9
A client with a chest tube has continuous bubbling in the water-seal chamber.
What should the nurse suspect?
A. Normal functioning
B. An air leak
C. Fluid overload
D. Lung re-expansion
Answer: An air leak
Rationale: Continuous bubbling in the water-seal chamber usually indicates
an air leak somewhere in the system. The nurse should assess the tubing and
connections.
