NCLEX RN Adult Medical Surgical
Nursing Exam 6 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
1. A client with heart failure is receiving furosemide. Which finding indicates
the medication is having the desired therapeutic effect?
A. Increased peripheral edema
B. Decreased urine output
C. Decreased dyspnea and peripheral edema
D. Increased jugular venous distention
Answer: Decreased dyspnea and peripheral edema
Rationale: Furosemide promotes diuresis, reducing excess fluid volume and
improving symptoms such as edema and dyspnea.
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. Monitor oxygen saturation
C. Encourage pursed-lip breathing
D. Oxygen at 15 L/min by nonrebreather mask continuously
Answer: Oxygen at 15 L/min by nonrebreather mask continuously
Rationale: Clients with COPD generally require carefully titrated oxygen.
Excessive oxygen administration can worsen carbon dioxide retention in
susceptible clients and should be used only when clinically indicated.
3. A client with diabetic ketoacidosis (DKA) has a blood glucose level of 520
mg/dL. Which intervention is the priority?
A. Administer potassium immediately
B. Begin isotonic IV fluid replacement as prescribed
,C. Give long-acting insulin
D. Restrict oral fluids
Answer: Begin isotonic IV fluid replacement as prescribed
Rationale: Severe dehydration is a major problem in DKA. Initial treatment
generally focuses on restoring circulating volume with isotonic fluids,
followed by insulin and electrolyte management.
4. A client taking warfarin has an international normalized ratio (INR) of 5.8.
Which action should the nurse anticipate?
A. Administer the next dose of warfarin
B. Encourage foods high in vitamin K
C. Hold warfarin and notify the provider
D. Administer aspirin
Answer: Hold warfarin and notify the provider
Rationale: An INR of 5.8 indicates excessive anticoagulation and an increased
bleeding risk. Warfarin should be withheld and the provider notified for
further management.
5. A client with a myocardial infarction suddenly develops severe dyspnea
and pink, frothy sputum. Which complication does the nurse suspect?
A. Pulmonary embolism
B. Pneumothorax
C. Acute pulmonary edema
D. Cardiac tamponade
Answer: Acute pulmonary edema
Rationale: Pink, frothy sputum with acute severe dyspnea is characteristic of
pulmonary edema caused by acute left ventricular failure.
6. A client with hyperkalemia has a potassium level of 6.8 mEq/L. Which
ECG finding should the nurse expect?
A. Prolonged QT interval
B. Tall, peaked T waves
C. U waves
,D. ST elevation
Answer: Tall, peaked T waves
Rationale: Hyperkalemia classically causes tall, peaked T waves and may
progress to widened QRS complexes and life-threatening dysrhythmias.
7. A client with SIADH has a serum sodium level of 118 mEq/L. Which
nursing intervention is most appropriate?
A. Encourage large amounts of water
B. Administer hypotonic IV fluids
C. Institute seizure precautions
D. Encourage a low-sodium diet
Answer: Institute seizure precautions
Rationale: Severe hyponatremia can cause cerebral edema, confusion,
seizures, and decreased level of consciousness. Safety precautions are
essential.
8. A client with a suspected pulmonary embolism suddenly develops chest
pain and dyspnea. What is the nurse's priority action?
A. Encourage ambulation
B. Place the client flat
C. Administer oxygen and assess respiratory status
D. Encourage oral fluids
Answer: Administer oxygen and assess respiratory status
Rationale: A pulmonary embolism can rapidly compromise oxygenation.
Supporting airway and breathing is the immediate priority while emergency
treatment is initiated.
9. A client with Addison disease is admitted with weakness, hypotension,
and vomiting. Which complication is the priority concern?
A. Hyperglycemia
B. Addisonian crisis
C. Hypertensive crisis
D. Cushing syndrome
, Answer: Addisonian crisis
Rationale: Severe cortisol deficiency can cause profound hypotension,
dehydration, electrolyte abnormalities, and shock. Immediate corticosteroid
and fluid therapy may be required.
10. Which assessment finding is most concerning in a client with increased
intracranial pressure?
A. Mild headache
B. Photophobia
C. Decreasing level of consciousness
D. Mild nausea
Answer: Decreasing level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening cerebral dysfunction and increased intracranial pressure.
11. A client with a tracheostomy suddenly becomes restless and has an
oxygen saturation of 82%. What should the nurse do first?
A. Call the family
B. Document the finding
C. Assess the tracheostomy for obstruction and suction if indicated
D. Give oral fluids
Answer: Assess the tracheostomy for obstruction and suction if indicated
Rationale: Sudden hypoxemia in a client with a tracheostomy may result from
mucus plugging or obstruction. Airway assessment and intervention are
immediate priorities.
12. A client receiving heparin develops bleeding from the gums and
hematuria. Which laboratory test is most important?
A. INR only
B. Hemoglobin A1c
C. aPTT
D. Serum sodium
Answer: aPTT
Nursing Exam 6 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026
1. A client with heart failure is receiving furosemide. Which finding indicates
the medication is having the desired therapeutic effect?
A. Increased peripheral edema
B. Decreased urine output
C. Decreased dyspnea and peripheral edema
D. Increased jugular venous distention
Answer: Decreased dyspnea and peripheral edema
Rationale: Furosemide promotes diuresis, reducing excess fluid volume and
improving symptoms such as edema and dyspnea.
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. Monitor oxygen saturation
C. Encourage pursed-lip breathing
D. Oxygen at 15 L/min by nonrebreather mask continuously
Answer: Oxygen at 15 L/min by nonrebreather mask continuously
Rationale: Clients with COPD generally require carefully titrated oxygen.
Excessive oxygen administration can worsen carbon dioxide retention in
susceptible clients and should be used only when clinically indicated.
3. A client with diabetic ketoacidosis (DKA) has a blood glucose level of 520
mg/dL. Which intervention is the priority?
A. Administer potassium immediately
B. Begin isotonic IV fluid replacement as prescribed
,C. Give long-acting insulin
D. Restrict oral fluids
Answer: Begin isotonic IV fluid replacement as prescribed
Rationale: Severe dehydration is a major problem in DKA. Initial treatment
generally focuses on restoring circulating volume with isotonic fluids,
followed by insulin and electrolyte management.
4. A client taking warfarin has an international normalized ratio (INR) of 5.8.
Which action should the nurse anticipate?
A. Administer the next dose of warfarin
B. Encourage foods high in vitamin K
C. Hold warfarin and notify the provider
D. Administer aspirin
Answer: Hold warfarin and notify the provider
Rationale: An INR of 5.8 indicates excessive anticoagulation and an increased
bleeding risk. Warfarin should be withheld and the provider notified for
further management.
5. A client with a myocardial infarction suddenly develops severe dyspnea
and pink, frothy sputum. Which complication does the nurse suspect?
A. Pulmonary embolism
B. Pneumothorax
C. Acute pulmonary edema
D. Cardiac tamponade
Answer: Acute pulmonary edema
Rationale: Pink, frothy sputum with acute severe dyspnea is characteristic of
pulmonary edema caused by acute left ventricular failure.
6. A client with hyperkalemia has a potassium level of 6.8 mEq/L. Which
ECG finding should the nurse expect?
A. Prolonged QT interval
B. Tall, peaked T waves
C. U waves
,D. ST elevation
Answer: Tall, peaked T waves
Rationale: Hyperkalemia classically causes tall, peaked T waves and may
progress to widened QRS complexes and life-threatening dysrhythmias.
7. A client with SIADH has a serum sodium level of 118 mEq/L. Which
nursing intervention is most appropriate?
A. Encourage large amounts of water
B. Administer hypotonic IV fluids
C. Institute seizure precautions
D. Encourage a low-sodium diet
Answer: Institute seizure precautions
Rationale: Severe hyponatremia can cause cerebral edema, confusion,
seizures, and decreased level of consciousness. Safety precautions are
essential.
8. A client with a suspected pulmonary embolism suddenly develops chest
pain and dyspnea. What is the nurse's priority action?
A. Encourage ambulation
B. Place the client flat
C. Administer oxygen and assess respiratory status
D. Encourage oral fluids
Answer: Administer oxygen and assess respiratory status
Rationale: A pulmonary embolism can rapidly compromise oxygenation.
Supporting airway and breathing is the immediate priority while emergency
treatment is initiated.
9. A client with Addison disease is admitted with weakness, hypotension,
and vomiting. Which complication is the priority concern?
A. Hyperglycemia
B. Addisonian crisis
C. Hypertensive crisis
D. Cushing syndrome
, Answer: Addisonian crisis
Rationale: Severe cortisol deficiency can cause profound hypotension,
dehydration, electrolyte abnormalities, and shock. Immediate corticosteroid
and fluid therapy may be required.
10. Which assessment finding is most concerning in a client with increased
intracranial pressure?
A. Mild headache
B. Photophobia
C. Decreasing level of consciousness
D. Mild nausea
Answer: Decreasing level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening cerebral dysfunction and increased intracranial pressure.
11. A client with a tracheostomy suddenly becomes restless and has an
oxygen saturation of 82%. What should the nurse do first?
A. Call the family
B. Document the finding
C. Assess the tracheostomy for obstruction and suction if indicated
D. Give oral fluids
Answer: Assess the tracheostomy for obstruction and suction if indicated
Rationale: Sudden hypoxemia in a client with a tracheostomy may result from
mucus plugging or obstruction. Airway assessment and intervention are
immediate priorities.
12. A client receiving heparin develops bleeding from the gums and
hematuria. Which laboratory test is most important?
A. INR only
B. Hemoglobin A1c
C. aPTT
D. Serum sodium
Answer: aPTT
