NCLEX RN Adult Medical Surgical
Nursing Exam 5 100 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. Blood pressure of 104/68 mm Hg
B. Urine output of 1,200 mL in 8 hours
C. Serum potassium of 2.8 mEq/L D. Weight loss of 1 kg in 24 hours
Answer: Serum potassium of 2.8 mEq/L
Rationale: Furosemide can cause significant potassium loss. Severe
hypokalemia increases the risk for life-threatening dysrhythmias and requires
prompt intervention.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which oxygen saturation is generally an appropriate target for a
client at risk for chronic carbon dioxide retention?
A. 70%–75%
B. 80%–85%
C. 88%–92%
D. 98%–100%
Answer: 88%–92%
Rationale: Clients with COPD who are at risk for hypercapnia are commonly
maintained at an oxygen saturation of approximately 88%–92% to provide
adequate oxygenation while minimizing excessive oxygen administration.
,3. A client with diabetic ketoacidosis (DKA) has a serum potassium of 3.1
mEq/L. Which prescription should the nurse question?
A. Begin IV regular insulin immediately
B. Administer IV fluids
C. Monitor cardiac rhythm continuously
D. Replace potassium as prescribed
Answer: Begin IV regular insulin immediately
Rationale: Insulin drives potassium into cells and can worsen hypokalemia.
When potassium is significantly low, potassium replacement is generally
required before insulin therapy is initiated.
4. A client is admitted with suspected bacterial meningitis. Which
intervention is the priority?
A. Place the client on contact precautions
B. Initiate droplet precautions
C. Encourage bright room lighting
D. Restrict all fluids
Answer: Initiate droplet precautions
Rationale: Bacterial meningitis can be transmitted through respiratory
droplets. Droplet precautions help protect healthcare workers and other
clients while diagnostic and antimicrobial treatment proceeds.
5. A client with a chest tube suddenly becomes severely dyspneic, and the
chest tube drainage system is found disconnected. What should the nurse do
first?
A. Clamp the chest tube
B. Place the end of the tube in sterile water
C. Remove the chest tube
D. Increase the wall suction
Answer: Place the end of the tube in sterile water
,Rationale: If the drainage system becomes disconnected, placing the distal
end of the chest tube in sterile water creates a temporary water seal and
helps prevent air from entering the pleural space.
6. A client with a head injury develops increasing intracranial pressure. Which
finding is most concerning?
A. Headache
B. Restlessness
C. Widening pulse pressure with bradycardia
D. Photophobia
Answer: Widening pulse pressure with bradycardia
Rationale: Widening pulse pressure, bradycardia, and irregular respirations
are components of Cushing's response, a late sign of increased intracranial
pressure and possible brain herniation.
7. 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. Obtain a urine specimen
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain can indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately to prevent
further exposure to the incompatible blood.
8. A client with Addison disease is at risk for adrenal crisis. Which finding
should the nurse recognize as most concerning?
A. Hypertension
B. Hypernatremia
, C. Severe hypotension
D. Bradycardia with hypertension
Answer: Severe hypotension
Rationale: Adrenal crisis causes inadequate cortisol and aldosterone,
resulting in severe hypotension, dehydration, electrolyte abnormalities,
hypoglycemia, and potentially shock.
9. A client with SIADH has a sodium level of 118 mEq/L. Which intervention is
the priority?
A. Encourage free-water intake
B. Institute seizure precautions
C. Administer hypotonic IV fluids
D. Encourage a low-sodium diet
Answer: Institute seizure precautions
Rationale: Severe hyponatremia can cause cerebral edema, confusion,
seizures, and coma. Seizure precautions are essential when sodium levels are
critically low.
10. A client with an acute myocardial infarction reports crushing chest pain.
Which prescribed medication should the nurse administer first when not
contraindicated?
A. Oral iron
B. Sublingual nitroglycerin
C. Long-acting insulin
D. Potassium chloride
Answer: Sublingual nitroglycerin
Rationale: Sublingual nitroglycerin decreases myocardial oxygen demand and
can relieve ischemic chest pain. The nurse should first assess blood pressure
and contraindications such as recent phosphodiesterase-5 inhibitor use.
Nursing Exam 5 100 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. Blood pressure of 104/68 mm Hg
B. Urine output of 1,200 mL in 8 hours
C. Serum potassium of 2.8 mEq/L D. Weight loss of 1 kg in 24 hours
Answer: Serum potassium of 2.8 mEq/L
Rationale: Furosemide can cause significant potassium loss. Severe
hypokalemia increases the risk for life-threatening dysrhythmias and requires
prompt intervention.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which oxygen saturation is generally an appropriate target for a
client at risk for chronic carbon dioxide retention?
A. 70%–75%
B. 80%–85%
C. 88%–92%
D. 98%–100%
Answer: 88%–92%
Rationale: Clients with COPD who are at risk for hypercapnia are commonly
maintained at an oxygen saturation of approximately 88%–92% to provide
adequate oxygenation while minimizing excessive oxygen administration.
,3. A client with diabetic ketoacidosis (DKA) has a serum potassium of 3.1
mEq/L. Which prescription should the nurse question?
A. Begin IV regular insulin immediately
B. Administer IV fluids
C. Monitor cardiac rhythm continuously
D. Replace potassium as prescribed
Answer: Begin IV regular insulin immediately
Rationale: Insulin drives potassium into cells and can worsen hypokalemia.
When potassium is significantly low, potassium replacement is generally
required before insulin therapy is initiated.
4. A client is admitted with suspected bacterial meningitis. Which
intervention is the priority?
A. Place the client on contact precautions
B. Initiate droplet precautions
C. Encourage bright room lighting
D. Restrict all fluids
Answer: Initiate droplet precautions
Rationale: Bacterial meningitis can be transmitted through respiratory
droplets. Droplet precautions help protect healthcare workers and other
clients while diagnostic and antimicrobial treatment proceeds.
5. A client with a chest tube suddenly becomes severely dyspneic, and the
chest tube drainage system is found disconnected. What should the nurse do
first?
A. Clamp the chest tube
B. Place the end of the tube in sterile water
C. Remove the chest tube
D. Increase the wall suction
Answer: Place the end of the tube in sterile water
,Rationale: If the drainage system becomes disconnected, placing the distal
end of the chest tube in sterile water creates a temporary water seal and
helps prevent air from entering the pleural space.
6. A client with a head injury develops increasing intracranial pressure. Which
finding is most concerning?
A. Headache
B. Restlessness
C. Widening pulse pressure with bradycardia
D. Photophobia
Answer: Widening pulse pressure with bradycardia
Rationale: Widening pulse pressure, bradycardia, and irregular respirations
are components of Cushing's response, a late sign of increased intracranial
pressure and possible brain herniation.
7. 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. Obtain a urine specimen
Answer: Stop the transfusion
Rationale: Fever, chills, and back pain can indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately to prevent
further exposure to the incompatible blood.
8. A client with Addison disease is at risk for adrenal crisis. Which finding
should the nurse recognize as most concerning?
A. Hypertension
B. Hypernatremia
, C. Severe hypotension
D. Bradycardia with hypertension
Answer: Severe hypotension
Rationale: Adrenal crisis causes inadequate cortisol and aldosterone,
resulting in severe hypotension, dehydration, electrolyte abnormalities,
hypoglycemia, and potentially shock.
9. A client with SIADH has a sodium level of 118 mEq/L. Which intervention is
the priority?
A. Encourage free-water intake
B. Institute seizure precautions
C. Administer hypotonic IV fluids
D. Encourage a low-sodium diet
Answer: Institute seizure precautions
Rationale: Severe hyponatremia can cause cerebral edema, confusion,
seizures, and coma. Seizure precautions are essential when sodium levels are
critically low.
10. A client with an acute myocardial infarction reports crushing chest pain.
Which prescribed medication should the nurse administer first when not
contraindicated?
A. Oral iron
B. Sublingual nitroglycerin
C. Long-acting insulin
D. Potassium chloride
Answer: Sublingual nitroglycerin
Rationale: Sublingual nitroglycerin decreases myocardial oxygen demand and
can relieve ischemic chest pain. The nurse should first assess blood pressure
and contraindications such as recent phosphodiesterase-5 inhibitor use.
