NCLEX RN Adult Medical Surgical
Nursing Exam 8 100 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 priority attention?
A. Blood pressure 104/68 mm Hg
B. Urine output of 900 mL in 8 hours
C. Potassium level of 2.8 mEq/L
D. Weight loss of 1 kg in 24 hours
Answer: C. Potassium level of 2.8 mEq/L
Rationale: Severe hypokalemia can cause life-threatening dysrhythmias.
Furosemide promotes potassium loss, so the potassium level requires
immediate attention.
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: C. 88%–92%
Rationale: For many clients with COPD who are at risk for hypercapnia,
controlled oxygen therapy targeting approximately 88%–92% helps provide
adequate oxygenation while reducing the risk of excessive oxygen
administration.
, 3. A client with diabetes mellitus is diaphoretic, confused, and trembling.
What should the nurse do first?
A. Administer regular insulin
B. Check the client's blood glucose level
C. Encourage the client to ambulate
D. Administer glucagon immediately
Answer: B. Check the client's blood glucose level
Rationale: The manifestations suggest hypoglycemia. If the client is conscious
and able to swallow, blood glucose should be checked promptly and followed
by appropriate treatment.
4. A client with a myocardial infarction reports sudden severe chest pain
despite receiving prescribed medication. Which action is the priority?
A. Reassess the pain in 30 minutes
B. Encourage oral fluids
C. Obtain a 12-lead ECG
D. Assist the client to ambulate
Answer: C. Obtain a 12-lead ECG
Rationale: Recurrent or worsening chest pain may indicate ongoing
myocardial ischemia. A 12-lead ECG helps identify acute ischemic changes
and guides urgent treatment.
5. A client with a suspected stroke has difficulty swallowing. Which
intervention is most appropriate?
A. Offer thin liquids
B. Place food on the affected side of the mouth
C. Keep the client NPO until swallowing is evaluated
D. Encourage rapid eating to prevent fatigue
Answer: C. Keep the client NPO until swallowing is evaluated
Rationale: Dysphagia after stroke increases the risk for aspiration. The client
should remain NPO until a swallowing assessment is completed.
, 6. A client taking warfarin has an INR of 5.8 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. Administer intramuscular vitamin K routinely
Answer: B. Hold warfarin and notify the provider
Rationale: An INR of 5.8 represents excessive anticoagulation and increases
bleeding risk. Warfarin is generally withheld and the provider notified for
further management.
7. A client with chronic kidney disease has a potassium level of 6.4 mEq/L.
Which finding is most concerning?
A. Muscle weakness
B. Nausea
C. Peaked T waves on ECG
D. Mild peripheral edema
Answer: C. Peaked T waves on ECG
Rationale: Hyperkalemia can produce dangerous cardiac conduction
abnormalities. Peaked T waves are an important early ECG manifestation and
require urgent intervention.
8. A client with pneumonia becomes increasingly confused and has a
respiratory rate of 32/min. Which action should the nurse take first?
A. Encourage oral fluids
B. Assess oxygen saturation and respiratory status
C. Administer a sedative
D. Place the client flat
Answer: B. Assess oxygen saturation and respiratory status
Rationale: Acute confusion and tachypnea may indicate worsening
hypoxemia or respiratory failure. Immediate respiratory assessment is the
priority.
, 9. A client with cirrhosis has ascites. Which dietary instruction is most
appropriate?
A. Increase sodium intake
B. Restrict sodium intake as prescribed
C. Increase processed foods
D. Consume unlimited fluids
Answer: B. Restrict sodium intake as prescribed
Rationale: Sodium restriction helps decrease fluid retention and is commonly
prescribed for clients with ascites related to cirrhosis.
10. A client with a newly created ileostomy asks why the stool is liquid.
Which response is best?
A. “The bowel is not functioning properly.”
B. “The ileum normally produces liquid stool because most water absorption
occurs in the colon.”
C. “Your stool will remain liquid permanently because of infection.”
D. “You should stop drinking fluids.”
Answer: B. The ileum normally produces liquid stool because most water
absorption occurs in the colon.
Rationale: An ileostomy bypasses the colon, where substantial water and
electrolyte absorption normally occurs. Therefore, ileostomy output is
typically liquid or semiliquid.
11. 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. Increase the infusion rate
Nursing Exam 8 100 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 priority attention?
A. Blood pressure 104/68 mm Hg
B. Urine output of 900 mL in 8 hours
C. Potassium level of 2.8 mEq/L
D. Weight loss of 1 kg in 24 hours
Answer: C. Potassium level of 2.8 mEq/L
Rationale: Severe hypokalemia can cause life-threatening dysrhythmias.
Furosemide promotes potassium loss, so the potassium level requires
immediate attention.
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: C. 88%–92%
Rationale: For many clients with COPD who are at risk for hypercapnia,
controlled oxygen therapy targeting approximately 88%–92% helps provide
adequate oxygenation while reducing the risk of excessive oxygen
administration.
, 3. A client with diabetes mellitus is diaphoretic, confused, and trembling.
What should the nurse do first?
A. Administer regular insulin
B. Check the client's blood glucose level
C. Encourage the client to ambulate
D. Administer glucagon immediately
Answer: B. Check the client's blood glucose level
Rationale: The manifestations suggest hypoglycemia. If the client is conscious
and able to swallow, blood glucose should be checked promptly and followed
by appropriate treatment.
4. A client with a myocardial infarction reports sudden severe chest pain
despite receiving prescribed medication. Which action is the priority?
A. Reassess the pain in 30 minutes
B. Encourage oral fluids
C. Obtain a 12-lead ECG
D. Assist the client to ambulate
Answer: C. Obtain a 12-lead ECG
Rationale: Recurrent or worsening chest pain may indicate ongoing
myocardial ischemia. A 12-lead ECG helps identify acute ischemic changes
and guides urgent treatment.
5. A client with a suspected stroke has difficulty swallowing. Which
intervention is most appropriate?
A. Offer thin liquids
B. Place food on the affected side of the mouth
C. Keep the client NPO until swallowing is evaluated
D. Encourage rapid eating to prevent fatigue
Answer: C. Keep the client NPO until swallowing is evaluated
Rationale: Dysphagia after stroke increases the risk for aspiration. The client
should remain NPO until a swallowing assessment is completed.
, 6. A client taking warfarin has an INR of 5.8 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. Administer intramuscular vitamin K routinely
Answer: B. Hold warfarin and notify the provider
Rationale: An INR of 5.8 represents excessive anticoagulation and increases
bleeding risk. Warfarin is generally withheld and the provider notified for
further management.
7. A client with chronic kidney disease has a potassium level of 6.4 mEq/L.
Which finding is most concerning?
A. Muscle weakness
B. Nausea
C. Peaked T waves on ECG
D. Mild peripheral edema
Answer: C. Peaked T waves on ECG
Rationale: Hyperkalemia can produce dangerous cardiac conduction
abnormalities. Peaked T waves are an important early ECG manifestation and
require urgent intervention.
8. A client with pneumonia becomes increasingly confused and has a
respiratory rate of 32/min. Which action should the nurse take first?
A. Encourage oral fluids
B. Assess oxygen saturation and respiratory status
C. Administer a sedative
D. Place the client flat
Answer: B. Assess oxygen saturation and respiratory status
Rationale: Acute confusion and tachypnea may indicate worsening
hypoxemia or respiratory failure. Immediate respiratory assessment is the
priority.
, 9. A client with cirrhosis has ascites. Which dietary instruction is most
appropriate?
A. Increase sodium intake
B. Restrict sodium intake as prescribed
C. Increase processed foods
D. Consume unlimited fluids
Answer: B. Restrict sodium intake as prescribed
Rationale: Sodium restriction helps decrease fluid retention and is commonly
prescribed for clients with ascites related to cirrhosis.
10. A client with a newly created ileostomy asks why the stool is liquid.
Which response is best?
A. “The bowel is not functioning properly.”
B. “The ileum normally produces liquid stool because most water absorption
occurs in the colon.”
C. “Your stool will remain liquid permanently because of infection.”
D. “You should stop drinking fluids.”
Answer: B. The ileum normally produces liquid stool because most water
absorption occurs in the colon.
Rationale: An ileostomy bypasses the colon, where substantial water and
electrolyte absorption normally occurs. Therefore, ileostomy output is
typically liquid or semiliquid.
11. 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. Increase the infusion rate
