NCLEX RN Adult Medical Surgical
Nursing Exam 4 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
1. A client with heart failure is receiving IV furosemide. Which finding requires
the nurse's immediate attention?
A. Urine output of 1,200 mL in 8 hours
B. Potassium level of 2.8 mEq/L
C. Blood pressure of 108/68 mm Hg
D. Weight loss of 1 kg in 24 hours
Answer: B. Potassium level of 2.8 mEq/L
Rationale: Severe hypokalemia increases the risk of life-threatening cardiac
dysrhythmias. Furosemide promotes potassium loss, so a potassium level of
2.8 mEq/L requires prompt intervention.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which prescription should the nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Oxygen saturation goal of 88%–92%
C. Oxygen at 10 L/min by nonrebreather mask continuously
D. Positioning in high-Fowler's position
Answer: C. Oxygen at 10 L/min by nonrebreather mask continuously
Rationale: Clients with COPD may have chronic carbon dioxide retention.
Excessive oxygen administration can worsen hypercapnia in some clients.
Oxygen should generally be carefully titrated to the prescribed target
saturation.
,3. A client with diabetic ketoacidosis (DKA) has a blood glucose of 620 mg/dL.
Which intervention should the nurse anticipate first?
A. Administer IV regular insulin
B. Begin rapid IV fluid replacement
C. Administer sodium bicarbonate
D. Give oral glucose
Answer: B. Begin rapid IV fluid replacement
Rationale: Severe dehydration is a major consequence of DKA. Initial
management focuses on restoring circulating volume with isotonic IV fluids,
followed by insulin therapy and electrolyte management.
4. A client with a chest tube suddenly develops severe dyspnea and absent
breath sounds on the affected side. What is the priority nursing action?
A. Clamp the chest tube
B. Increase the water-seal suction
C. Assess the tubing for obstruction or disconnection
D. Place the client flat
Answer: C. Assess the tubing for obstruction or disconnection
Rationale: Sudden respiratory distress with absent breath sounds may
indicate a tension pneumothorax or chest-tube malfunction. The nurse should
immediately assess the system for kinks, obstruction, or disconnection while
providing emergency support.
5. A client receiving warfarin has an INR of 5.8 and no active bleeding. Which
prescription should the nurse anticipate?
A. Administer vitamin K as prescribed
B. Administer another dose of warfarin
C. Give aspirin
D. Encourage foods high in sodium
,Answer: A. Administer vitamin K as prescribed
Rationale: An INR of 5.8 represents excessive anticoagulation and increases
bleeding risk. Warfarin is typically held, and vitamin K may be prescribed
depending on the INR and clinical circumstances.
6. A client with suspected bacterial meningitis is admitted to the unit. Which
intervention is most appropriate?
A. Initiate airborne precautions
B. Initiate droplet precautions
C. Place the client in protective isolation
D. Use contact precautions only
Answer: B. Initiate droplet precautions
Rationale: Bacterial meningitis caused by organisms such as meningococcus
requires droplet precautions in addition to standard precautions, particularly
during the initial period of treatment.
7. A client with cirrhosis has increasing abdominal distention and shortness of
breath. Which intervention is most appropriate?
A. Encourage increased sodium intake
B. Restrict sodium as prescribed
C. Encourage large amounts of oral fluids
D. Place the client in Trendelenburg position
Answer: B. Restrict sodium as prescribed
Rationale: Sodium restriction helps reduce fluid retention and ascites in clients
with cirrhosis. Diuretics and other treatments may also be prescribed.
8. A client with acute pancreatitis reports severe epigastric pain radiating to the
back. Which intervention should the nurse prioritize?
A. Encourage a high-fat diet
B. Maintain prescribed bowel rest and IV fluids
C. Place the client in a supine position
, D. Administer oral pancreatic enzymes immediately
Answer: B. Maintain prescribed bowel rest and IV fluids
Rationale: Acute pancreatitis often requires pancreatic rest, aggressive fluid
management, pain control, and monitoring for complications. Oral intake is
generally withheld initially in severe cases.
9. A client with Addison disease has weakness, hypotension, and hyperkalemia.
Which medication should the nurse expect to administer?
A. Hydrocortisone
B. Levothyroxine
C. Methimazole
D. Furosemide
Answer: A. Hydrocortisone
Rationale: Addison disease results from adrenal insufficiency. Glucocorticoid
replacement such as hydrocortisone is essential and may be urgently required
during an adrenal crisis.
10. A client with hyperthyroidism develops fever, severe tachycardia, agitation,
and diaphoresis. Which complication should the nurse suspect?
A. Myxedema coma
B. Thyroid storm
C. Hypoglycemia
D. Adrenal crisis
Answer: B. Thyroid storm
Rationale: Thyroid storm is a life-threatening exacerbation of hyperthyroidism
characterized by hyperthermia, tachycardia, hypertension or hypotension,
agitation, and gastrointestinal symptoms.
11. A client with an acute ischemic stroke has difficulty swallowing. What
should the nurse do before giving oral medications?
Nursing Exam 4 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
1. A client with heart failure is receiving IV furosemide. Which finding requires
the nurse's immediate attention?
A. Urine output of 1,200 mL in 8 hours
B. Potassium level of 2.8 mEq/L
C. Blood pressure of 108/68 mm Hg
D. Weight loss of 1 kg in 24 hours
Answer: B. Potassium level of 2.8 mEq/L
Rationale: Severe hypokalemia increases the risk of life-threatening cardiac
dysrhythmias. Furosemide promotes potassium loss, so a potassium level of
2.8 mEq/L requires prompt intervention.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which prescription should the nurse question?
A. Oxygen at 2 L/min by nasal cannula
B. Oxygen saturation goal of 88%–92%
C. Oxygen at 10 L/min by nonrebreather mask continuously
D. Positioning in high-Fowler's position
Answer: C. Oxygen at 10 L/min by nonrebreather mask continuously
Rationale: Clients with COPD may have chronic carbon dioxide retention.
Excessive oxygen administration can worsen hypercapnia in some clients.
Oxygen should generally be carefully titrated to the prescribed target
saturation.
,3. A client with diabetic ketoacidosis (DKA) has a blood glucose of 620 mg/dL.
Which intervention should the nurse anticipate first?
A. Administer IV regular insulin
B. Begin rapid IV fluid replacement
C. Administer sodium bicarbonate
D. Give oral glucose
Answer: B. Begin rapid IV fluid replacement
Rationale: Severe dehydration is a major consequence of DKA. Initial
management focuses on restoring circulating volume with isotonic IV fluids,
followed by insulin therapy and electrolyte management.
4. A client with a chest tube suddenly develops severe dyspnea and absent
breath sounds on the affected side. What is the priority nursing action?
A. Clamp the chest tube
B. Increase the water-seal suction
C. Assess the tubing for obstruction or disconnection
D. Place the client flat
Answer: C. Assess the tubing for obstruction or disconnection
Rationale: Sudden respiratory distress with absent breath sounds may
indicate a tension pneumothorax or chest-tube malfunction. The nurse should
immediately assess the system for kinks, obstruction, or disconnection while
providing emergency support.
5. A client receiving warfarin has an INR of 5.8 and no active bleeding. Which
prescription should the nurse anticipate?
A. Administer vitamin K as prescribed
B. Administer another dose of warfarin
C. Give aspirin
D. Encourage foods high in sodium
,Answer: A. Administer vitamin K as prescribed
Rationale: An INR of 5.8 represents excessive anticoagulation and increases
bleeding risk. Warfarin is typically held, and vitamin K may be prescribed
depending on the INR and clinical circumstances.
6. A client with suspected bacterial meningitis is admitted to the unit. Which
intervention is most appropriate?
A. Initiate airborne precautions
B. Initiate droplet precautions
C. Place the client in protective isolation
D. Use contact precautions only
Answer: B. Initiate droplet precautions
Rationale: Bacterial meningitis caused by organisms such as meningococcus
requires droplet precautions in addition to standard precautions, particularly
during the initial period of treatment.
7. A client with cirrhosis has increasing abdominal distention and shortness of
breath. Which intervention is most appropriate?
A. Encourage increased sodium intake
B. Restrict sodium as prescribed
C. Encourage large amounts of oral fluids
D. Place the client in Trendelenburg position
Answer: B. Restrict sodium as prescribed
Rationale: Sodium restriction helps reduce fluid retention and ascites in clients
with cirrhosis. Diuretics and other treatments may also be prescribed.
8. A client with acute pancreatitis reports severe epigastric pain radiating to the
back. Which intervention should the nurse prioritize?
A. Encourage a high-fat diet
B. Maintain prescribed bowel rest and IV fluids
C. Place the client in a supine position
, D. Administer oral pancreatic enzymes immediately
Answer: B. Maintain prescribed bowel rest and IV fluids
Rationale: Acute pancreatitis often requires pancreatic rest, aggressive fluid
management, pain control, and monitoring for complications. Oral intake is
generally withheld initially in severe cases.
9. A client with Addison disease has weakness, hypotension, and hyperkalemia.
Which medication should the nurse expect to administer?
A. Hydrocortisone
B. Levothyroxine
C. Methimazole
D. Furosemide
Answer: A. Hydrocortisone
Rationale: Addison disease results from adrenal insufficiency. Glucocorticoid
replacement such as hydrocortisone is essential and may be urgently required
during an adrenal crisis.
10. A client with hyperthyroidism develops fever, severe tachycardia, agitation,
and diaphoresis. Which complication should the nurse suspect?
A. Myxedema coma
B. Thyroid storm
C. Hypoglycemia
D. Adrenal crisis
Answer: B. Thyroid storm
Rationale: Thyroid storm is a life-threatening exacerbation of hyperthyroidism
characterized by hyperthermia, tachycardia, hypertension or hypotension,
agitation, and gastrointestinal symptoms.
11. A client with an acute ischemic stroke has difficulty swallowing. What
should the nurse do before giving oral medications?
