NCLEX RN Clinical Judgment Exam 1
100 Questions And Correct Answers
(Verified Answers) Plus Rationales
2026 Q&A Instant Download Pdf
1. A nurse is caring for a client who suddenly develops shortness of breath,
chest pain, and an oxygen saturation of 86% on room air. Which action should
the nurse take first?
A. Obtain a 12-lead ECG
B. Apply oxygen
C. Notify the health care provider
D. Administer prescribed analgesia
Answer: B. Apply oxygen
Rationale: The client is experiencing acute hypoxemia. Using the ABC priority
framework, airway and breathing take priority. Oxygen should be applied
promptly while further assessment and interventions are initiated.
2. A client with heart failure reports increasing dyspnea and has bilateral
crackles. Which finding requires the most immediate intervention?
A. 2+ bilateral ankle edema
B. Weight gain of 2 kg in 3 days
C. Oxygen saturation of 84%
D. Blood pressure of 148/88 mm Hg
Answer: C. Oxygen saturation of 84%
Rationale: Severe hypoxemia indicates impaired oxygenation and is the most
immediate threat to life. The nurse should address breathing before less
urgent manifestations of fluid overload.
,3. A client with diabetes is confused, diaphoretic, and trembling. 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. Recheck the glucose in 1 hour
D. Administer the client's long-acting insulin
Answer: B. Give 15 g of rapid-acting carbohydrate
Rationale: The client has symptomatic hypoglycemia and is conscious enough
to receive oral treatment. Rapid-acting carbohydrate should be given,
followed by reassessment of glucose.
4. 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. Increase the IV infusion rate
Answer: B. Stop the transfusion
Rationale: Fever, chills, and back pain may indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately, and the
IV line maintained with appropriate compatible solution according to
protocol.
5. A postoperative client becomes restless and has a respiratory rate of 30/min
with an oxygen saturation of 88%. Which assessment is the priority?
A. Bowel sounds
B. Surgical incision
C. Airway patency
D. Urine output
,Answer: C. Airway patency
Rationale: Restlessness and hypoxemia may indicate respiratory compromise.
Airway and breathing must be assessed immediately because oxygenation
problems can rapidly become life-threatening.
6. A client with suspected stroke has facial drooping and slurred speech. Which
action is most important before giving oral medications?
A. Assess bowel sounds
B. Perform a swallowing assessment
C. Obtain the client's weight
D. Assess peripheral pulses
Answer: B. Perform a swallowing assessment
Rationale: Stroke can impair swallowing and increase the risk of aspiration.
Oral intake should be withheld until swallowing ability has been evaluated.
7. A client with COPD has an oxygen saturation of 89% and is receiving oxygen
at 2 L/min via nasal cannula. The client is alert and breathing comfortably.
What should the nurse do?
A. Increase oxygen to 10 L/min
B. Discontinue oxygen
C. Continue the prescribed oxygen therapy
D. Place the client in a supine position
Answer: C. Continue the prescribed oxygen therapy
Rationale: Oxygen therapy should be administered at the prescribed target
level. Excessive oxygen can worsen carbon dioxide retention in some clients
with COPD, so oxygen should be titrated carefully rather than automatically
maximized.
8. A client receiving IV morphine becomes difficult to arouse and has a
respiratory rate of 7/min. Which medication should the nurse anticipate
administering?
, A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Answer: B. Naloxone
Rationale: Severe respiratory depression following opioid administration
suggests opioid toxicity. Naloxone is an opioid antagonist used to reverse
opioid-induced respiratory depression.
9. A client with potassium of 6.8 mEq/L has peaked T waves on the ECG. Which
prescribed medication should the nurse anticipate administering first to
stabilize the cardiac membrane?
A. Calcium gluconate
B. Sodium chloride
C. Furosemide
D. Oral potassium
Answer: A. Calcium gluconate
Rationale: Severe hyperkalemia with ECG changes is an emergency. IV
calcium gluconate helps stabilize the myocardial membrane while other
therapies are used to reduce serum potassium.
10. A client with sepsis has a blood pressure of 82/48 mm Hg, heart rate of
124/min, and cool extremities. Which intervention is the priority?
A. Restrict fluids
B. Begin prescribed IV fluid resuscitation
C. Encourage ambulation
D. Administer oral fluids only
Answer: B. Begin prescribed IV fluid resuscitation
Rationale: Hypotension and signs of poor perfusion suggest septic shock.
Rapid IV fluid resuscitation is an important initial intervention to improve
circulating volume and tissue perfusion.
100 Questions And Correct Answers
(Verified Answers) Plus Rationales
2026 Q&A Instant Download Pdf
1. A nurse is caring for a client who suddenly develops shortness of breath,
chest pain, and an oxygen saturation of 86% on room air. Which action should
the nurse take first?
A. Obtain a 12-lead ECG
B. Apply oxygen
C. Notify the health care provider
D. Administer prescribed analgesia
Answer: B. Apply oxygen
Rationale: The client is experiencing acute hypoxemia. Using the ABC priority
framework, airway and breathing take priority. Oxygen should be applied
promptly while further assessment and interventions are initiated.
2. A client with heart failure reports increasing dyspnea and has bilateral
crackles. Which finding requires the most immediate intervention?
A. 2+ bilateral ankle edema
B. Weight gain of 2 kg in 3 days
C. Oxygen saturation of 84%
D. Blood pressure of 148/88 mm Hg
Answer: C. Oxygen saturation of 84%
Rationale: Severe hypoxemia indicates impaired oxygenation and is the most
immediate threat to life. The nurse should address breathing before less
urgent manifestations of fluid overload.
,3. A client with diabetes is confused, diaphoretic, and trembling. 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. Recheck the glucose in 1 hour
D. Administer the client's long-acting insulin
Answer: B. Give 15 g of rapid-acting carbohydrate
Rationale: The client has symptomatic hypoglycemia and is conscious enough
to receive oral treatment. Rapid-acting carbohydrate should be given,
followed by reassessment of glucose.
4. 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. Increase the IV infusion rate
Answer: B. Stop the transfusion
Rationale: Fever, chills, and back pain may indicate an acute hemolytic
transfusion reaction. The transfusion must be stopped immediately, and the
IV line maintained with appropriate compatible solution according to
protocol.
5. A postoperative client becomes restless and has a respiratory rate of 30/min
with an oxygen saturation of 88%. Which assessment is the priority?
A. Bowel sounds
B. Surgical incision
C. Airway patency
D. Urine output
,Answer: C. Airway patency
Rationale: Restlessness and hypoxemia may indicate respiratory compromise.
Airway and breathing must be assessed immediately because oxygenation
problems can rapidly become life-threatening.
6. A client with suspected stroke has facial drooping and slurred speech. Which
action is most important before giving oral medications?
A. Assess bowel sounds
B. Perform a swallowing assessment
C. Obtain the client's weight
D. Assess peripheral pulses
Answer: B. Perform a swallowing assessment
Rationale: Stroke can impair swallowing and increase the risk of aspiration.
Oral intake should be withheld until swallowing ability has been evaluated.
7. A client with COPD has an oxygen saturation of 89% and is receiving oxygen
at 2 L/min via nasal cannula. The client is alert and breathing comfortably.
What should the nurse do?
A. Increase oxygen to 10 L/min
B. Discontinue oxygen
C. Continue the prescribed oxygen therapy
D. Place the client in a supine position
Answer: C. Continue the prescribed oxygen therapy
Rationale: Oxygen therapy should be administered at the prescribed target
level. Excessive oxygen can worsen carbon dioxide retention in some clients
with COPD, so oxygen should be titrated carefully rather than automatically
maximized.
8. A client receiving IV morphine becomes difficult to arouse and has a
respiratory rate of 7/min. Which medication should the nurse anticipate
administering?
, A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Answer: B. Naloxone
Rationale: Severe respiratory depression following opioid administration
suggests opioid toxicity. Naloxone is an opioid antagonist used to reverse
opioid-induced respiratory depression.
9. A client with potassium of 6.8 mEq/L has peaked T waves on the ECG. Which
prescribed medication should the nurse anticipate administering first to
stabilize the cardiac membrane?
A. Calcium gluconate
B. Sodium chloride
C. Furosemide
D. Oral potassium
Answer: A. Calcium gluconate
Rationale: Severe hyperkalemia with ECG changes is an emergency. IV
calcium gluconate helps stabilize the myocardial membrane while other
therapies are used to reduce serum potassium.
10. A client with sepsis has a blood pressure of 82/48 mm Hg, heart rate of
124/min, and cool extremities. Which intervention is the priority?
A. Restrict fluids
B. Begin prescribed IV fluid resuscitation
C. Encourage ambulation
D. Administer oral fluids only
Answer: B. Begin prescribed IV fluid resuscitation
Rationale: Hypotension and signs of poor perfusion suggest septic shock.
Rapid IV fluid resuscitation is an important initial intervention to improve
circulating volume and tissue perfusion.
