NCLEX-RN PRACTICE EXAM QUESTIONS
AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A |
INSTANT DOWNLOAD PDF
1. A nurse is caring for a client with heart failure who has
dyspnea and bilateral lower extremity edema. Which action
should the nurse take first?
A. Elevate the legs
B. Administer diuretics as prescribed
C. Place the client in high-Fowler’s position
D. Monitor daily weight
Answer: C. Place the client in high-Fowler’s position
Rationale: Prioritization is based on airway and breathing.
High-Fowler’s position helps improve oxygenation and relieve
dyspnea in clients with heart failure.
2. A client is prescribed warfarin. Which laboratory test should
the nurse monitor to evaluate the effectiveness of the
therapy?
A. aPTT
B. INR
,C. Platelet count
D. WBC
Answer: B. INR
Rationale: INR (International Normalized Ratio) is used to
monitor warfarin therapy effectiveness. aPTT is for heparin,
platelet count evaluates bleeding risk.
3. A nurse is teaching a client with diabetes mellitus about
foot care. Which statement by the client indicates
understanding?
A. “I can soak my feet daily to soften the skin.”
B. “I should inspect my feet every day.”
C. “I should trim my toenails quickly with scissors.”
D. “I can go barefoot if the floor is clean.”
Answer: B. “I should inspect my feet every day.”
Rationale: Daily inspection helps prevent complications such
as ulcers or infections. Soaking and improper trimming can
increase risk of injury.
4. A client with chronic kidney disease has hyperkalemia.
Which intervention should the nurse anticipate?
A. Administer sodium polystyrene sulfonate
B. Restrict calcium intake
,C. Encourage high-potassium foods
D. Administer magnesium sulfate
Answer: A. Administer sodium polystyrene sulfonate
Rationale: Sodium polystyrene sulfonate (Kayexalate) binds
potassium in the gut, lowering serum potassium levels. High-
potassium foods are contraindicated.
5. A nurse is preparing to administer morphine to a client for
severe pain. Which assessment is priority before giving the
medication?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Temperature
Answer: C. Respiratory rate
Rationale: Opioids like morphine can depress respiration.
Assessing respiratory rate ensures patient safety prior to
administration.
6. A client is receiving a blood transfusion and develops chills,
fever, and back pain. What is the nurse’s first action?
A. Administer antipyretics
B. Stop the transfusion and notify the provider
, C. Reduce the transfusion rate
D. Document the reaction
Answer: B. Stop the transfusion and notify the provider
Rationale: These are signs of a hemolytic transfusion reaction,
which can be life-threatening. Immediate cessation and
notification are critical.
7. A nurse is caring for a client with COPD who has oxygen
saturation of 88%. Which oxygen delivery method is most
appropriate?
A. Nasal cannula at 1–2 L/min
B. Non-rebreather mask at 15 L/min
C. Simple face mask at 5 L/min
D. Venturi mask at 4 L/min
Answer: D. Venturi mask at 4 L/min
Rationale: Venturi masks deliver precise oxygen
concentrations, which is important in COPD to prevent CO₂
retention.
8. A nurse is assessing a client with hypovolemic shock. Which
sign is most indicative of this condition?
A. Bradycardia
B. Hypertension
AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A |
INSTANT DOWNLOAD PDF
1. A nurse is caring for a client with heart failure who has
dyspnea and bilateral lower extremity edema. Which action
should the nurse take first?
A. Elevate the legs
B. Administer diuretics as prescribed
C. Place the client in high-Fowler’s position
D. Monitor daily weight
Answer: C. Place the client in high-Fowler’s position
Rationale: Prioritization is based on airway and breathing.
High-Fowler’s position helps improve oxygenation and relieve
dyspnea in clients with heart failure.
2. A client is prescribed warfarin. Which laboratory test should
the nurse monitor to evaluate the effectiveness of the
therapy?
A. aPTT
B. INR
,C. Platelet count
D. WBC
Answer: B. INR
Rationale: INR (International Normalized Ratio) is used to
monitor warfarin therapy effectiveness. aPTT is for heparin,
platelet count evaluates bleeding risk.
3. A nurse is teaching a client with diabetes mellitus about
foot care. Which statement by the client indicates
understanding?
A. “I can soak my feet daily to soften the skin.”
B. “I should inspect my feet every day.”
C. “I should trim my toenails quickly with scissors.”
D. “I can go barefoot if the floor is clean.”
Answer: B. “I should inspect my feet every day.”
Rationale: Daily inspection helps prevent complications such
as ulcers or infections. Soaking and improper trimming can
increase risk of injury.
4. A client with chronic kidney disease has hyperkalemia.
Which intervention should the nurse anticipate?
A. Administer sodium polystyrene sulfonate
B. Restrict calcium intake
,C. Encourage high-potassium foods
D. Administer magnesium sulfate
Answer: A. Administer sodium polystyrene sulfonate
Rationale: Sodium polystyrene sulfonate (Kayexalate) binds
potassium in the gut, lowering serum potassium levels. High-
potassium foods are contraindicated.
5. A nurse is preparing to administer morphine to a client for
severe pain. Which assessment is priority before giving the
medication?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Temperature
Answer: C. Respiratory rate
Rationale: Opioids like morphine can depress respiration.
Assessing respiratory rate ensures patient safety prior to
administration.
6. A client is receiving a blood transfusion and develops chills,
fever, and back pain. What is the nurse’s first action?
A. Administer antipyretics
B. Stop the transfusion and notify the provider
, C. Reduce the transfusion rate
D. Document the reaction
Answer: B. Stop the transfusion and notify the provider
Rationale: These are signs of a hemolytic transfusion reaction,
which can be life-threatening. Immediate cessation and
notification are critical.
7. A nurse is caring for a client with COPD who has oxygen
saturation of 88%. Which oxygen delivery method is most
appropriate?
A. Nasal cannula at 1–2 L/min
B. Non-rebreather mask at 15 L/min
C. Simple face mask at 5 L/min
D. Venturi mask at 4 L/min
Answer: D. Venturi mask at 4 L/min
Rationale: Venturi masks deliver precise oxygen
concentrations, which is important in COPD to prevent CO₂
retention.
8. A nurse is assessing a client with hypovolemic shock. Which
sign is most indicative of this condition?
A. Bradycardia
B. Hypertension
