NCLEX-RN NGN 2026 Clinical Judgment Exam: 75 NCLEX Questions with Answers
and Rationales
1. During morning assessment, a nurse notes sudden dyspnea, pleuritic chest pain,
tachycardia in a client being treated for postoperative pulmonary embolism. Which
action should the nurse take first?
A. Delay intervention until all scheduled medications have been administered
B. Document the findings and reassess at the end of the shift
C. assess oxygenation and respiratory status immediately
D. Provide routine comfort measures before further assessment
Correct Answer: C. assess oxygenation and respiratory status immediately
Rationale: The findings are abrupt and potentially life-threatening, making airway and
breathing the first priorities. Rapid assessment identifies the degree of compromise and
supports immediate escalation. Delaying for documentation, analgesia, or routine care could
allow severe hypoxemia or hemodynamic instability to progress.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Recognize cues; Act
2. During morning assessment, a nurse notes diaphoresis, tremor, confusion, hunger in
a client being treated for hypoglycemia. Which action should the nurse take first?
A. Provide routine comfort measures before further assessment
B. Delay intervention until all scheduled medications have been administered
C. Document the findings and reassess at the end of the shift
D. check the blood glucose and treat promptly if low
Correct Answer: D. check the blood glucose and treat promptly if low
Rationale: These neurogenic and neuroglycopenic findings are classic for hypoglycemia. A
bedside glucose check rapidly confirms the problem and guides treatment with fast-acting
carbohydrate or IV dextrose/glucagon depending on status. Insulin would worsen the
condition.
NCLEX Client Need: Reduction of Risk Potential
Clinical Judgment Focus: Analyze cues; Act
,3. During morning assessment, a nurse notes respiratory rate 8/min with increasing
somnolence in a client being treated for opioid respiratory depression. Which action
should the nurse take first?
A. Document the findings and reassess at the end of the shift
B. Provide routine comfort measures before further assessment
C. hold the opioid, assess airway and breathing, and prepare to administer naloxone per
protocol
D. Delay intervention until all scheduled medications have been administered
Correct Answer: C. hold the opioid, assess airway and breathing, and prepare to
administer naloxone per protocol
Rationale: A respiratory rate of 8/min with sedation indicates clinically significant opioid effect.
The nurse should stop further opioid administration, support ventilation, and follow
reversal/rescue protocols. Waiting or giving another sedating drug risks respiratory arrest.
NCLEX Client Need: Pharmacological and Parenteral Therapies
Clinical Judgment Focus: Recognize cues; Take action
4. During morning assessment, a nurse notes new facial droop, unilateral weakness,
and slurred speech in a client being treated for acute stroke. Which action should the
nurse take first?
A. Provide routine comfort measures before further assessment
B. Document the findings and reassess at the end of the shift
C. activate the stroke response and establish the time last known well
D. Delay intervention until all scheduled medications have been administered
Correct Answer: C. activate the stroke response and establish the time last known well
Rationale: Stroke treatment is time dependent. Identifying last-known-well time and activating
the stroke pathway allows rapid imaging and evaluation for reperfusion therapy. Routine
reassessment or oral intake must not delay emergency evaluation.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Recognize cues; Prioritize hypotheses
5. During morning assessment, a nurse notes fever, tachycardia, hypotension, altered
mentation in a client being treated for sepsis. Which action should the nurse take first?
A. Delay intervention until all scheduled medications have been administered
, B. Document the findings and reassess at the end of the shift
C. initiate sepsis-focused assessment and notify the provider/rapid response while obtaining
ordered cultures and lactate
D. Provide routine comfort measures before further assessment
Correct Answer: C. initiate sepsis-focused assessment and notify the provider/rapid
response while obtaining ordered cultures and lactate
Rationale: Hypotension and altered mentation with infection suggest organ dysfunction from
sepsis. Early recognition and prompt treatment, including cultures, lactate, fluids, and
antimicrobials as ordered, improve outcomes. Nonurgent comfort measures should not delay
stabilization.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Analyze cues; Take action
6. During morning assessment, a nurse notes muscle weakness with peaked T waves
on ECG in a client being treated for hyperkalemia. Which action should the nurse take
first?
A. Provide routine comfort measures before further assessment
B. Document the findings and reassess at the end of the shift
C. place the client on cardiac monitoring and notify the provider for urgent treatment
D. Delay intervention until all scheduled medications have been administered
Correct Answer: C. place the client on cardiac monitoring and notify the provider for
urgent treatment
Rationale: Peaked T waves indicate cardiac effects of hyperkalemia and risk for lethal
dysrhythmias. Continuous monitoring and rapid treatment are priorities. Dietary teaching is
important later but does not address the immediate threat.
NCLEX Client Need: Reduction of Risk Potential
Clinical Judgment Focus: Prioritize hypotheses; Take action
7. During morning assessment, a nurse notes severe dyspnea, unilateral absent breath
sounds, hypotension, tracheal deviation in a client being treated for tension
pneumothorax. Which action should the nurse take first?
A. Provide routine comfort measures before further assessment
B. Delay intervention until all scheduled medications have been administered
C. Document the findings and reassess at the end of the shift
, D. call for emergency assistance and prepare for immediate decompression
Correct Answer: D. call for emergency assistance and prepare for immediate
decompression
Rationale: These findings indicate tension pneumothorax with obstructive shock. The client
can deteriorate rapidly, so emergency decompression is required. Waiting for routine imaging
before escalation is unsafe in an unstable client.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Recognize cues; Take action
8. During morning assessment, a nurse notes wheezing, facial swelling, hypotension
after medication in a client being treated for anaphylaxis. Which action should the nurse
take first?
A. administer IM epinephrine promptly and support airway/breathing
B. Provide routine comfort measures before further assessment
C. Document the findings and reassess at the end of the shift
D. Delay intervention until all scheduled medications have been administered
Correct Answer: A. administer IM epinephrine promptly and support airway/breathing
Rationale: Anaphylaxis threatens airway and circulation. Intramuscular epinephrine is the first-
line treatment because it reverses bronchospasm and vasodilation. Antihistamines are
adjuncts and should not delay epinephrine.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Take action; Evaluate outcomes
9. During morning assessment, a nurse notes polyuria, dehydration, abdominal pain,
Kussmaul respirations, high glucose in a client being treated for DKA. Which action
should the nurse take first?
A. Document the findings and reassess at the end of the shift
B. Delay intervention until all scheduled medications have been administered
C. Provide routine comfort measures before further assessment
D. begin isotonic IV fluids and follow the DKA protocol
Correct Answer: D. begin isotonic IV fluids and follow the DKA protocol
Rationale: DKA causes severe volume depletion and metabolic acidosis. Initial isotonic fluid
resuscitation restores perfusion; insulin and electrolyte management follow according to
and Rationales
1. During morning assessment, a nurse notes sudden dyspnea, pleuritic chest pain,
tachycardia in a client being treated for postoperative pulmonary embolism. Which
action should the nurse take first?
A. Delay intervention until all scheduled medications have been administered
B. Document the findings and reassess at the end of the shift
C. assess oxygenation and respiratory status immediately
D. Provide routine comfort measures before further assessment
Correct Answer: C. assess oxygenation and respiratory status immediately
Rationale: The findings are abrupt and potentially life-threatening, making airway and
breathing the first priorities. Rapid assessment identifies the degree of compromise and
supports immediate escalation. Delaying for documentation, analgesia, or routine care could
allow severe hypoxemia or hemodynamic instability to progress.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Recognize cues; Act
2. During morning assessment, a nurse notes diaphoresis, tremor, confusion, hunger in
a client being treated for hypoglycemia. Which action should the nurse take first?
A. Provide routine comfort measures before further assessment
B. Delay intervention until all scheduled medications have been administered
C. Document the findings and reassess at the end of the shift
D. check the blood glucose and treat promptly if low
Correct Answer: D. check the blood glucose and treat promptly if low
Rationale: These neurogenic and neuroglycopenic findings are classic for hypoglycemia. A
bedside glucose check rapidly confirms the problem and guides treatment with fast-acting
carbohydrate or IV dextrose/glucagon depending on status. Insulin would worsen the
condition.
NCLEX Client Need: Reduction of Risk Potential
Clinical Judgment Focus: Analyze cues; Act
,3. During morning assessment, a nurse notes respiratory rate 8/min with increasing
somnolence in a client being treated for opioid respiratory depression. Which action
should the nurse take first?
A. Document the findings and reassess at the end of the shift
B. Provide routine comfort measures before further assessment
C. hold the opioid, assess airway and breathing, and prepare to administer naloxone per
protocol
D. Delay intervention until all scheduled medications have been administered
Correct Answer: C. hold the opioid, assess airway and breathing, and prepare to
administer naloxone per protocol
Rationale: A respiratory rate of 8/min with sedation indicates clinically significant opioid effect.
The nurse should stop further opioid administration, support ventilation, and follow
reversal/rescue protocols. Waiting or giving another sedating drug risks respiratory arrest.
NCLEX Client Need: Pharmacological and Parenteral Therapies
Clinical Judgment Focus: Recognize cues; Take action
4. During morning assessment, a nurse notes new facial droop, unilateral weakness,
and slurred speech in a client being treated for acute stroke. Which action should the
nurse take first?
A. Provide routine comfort measures before further assessment
B. Document the findings and reassess at the end of the shift
C. activate the stroke response and establish the time last known well
D. Delay intervention until all scheduled medications have been administered
Correct Answer: C. activate the stroke response and establish the time last known well
Rationale: Stroke treatment is time dependent. Identifying last-known-well time and activating
the stroke pathway allows rapid imaging and evaluation for reperfusion therapy. Routine
reassessment or oral intake must not delay emergency evaluation.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Recognize cues; Prioritize hypotheses
5. During morning assessment, a nurse notes fever, tachycardia, hypotension, altered
mentation in a client being treated for sepsis. Which action should the nurse take first?
A. Delay intervention until all scheduled medications have been administered
, B. Document the findings and reassess at the end of the shift
C. initiate sepsis-focused assessment and notify the provider/rapid response while obtaining
ordered cultures and lactate
D. Provide routine comfort measures before further assessment
Correct Answer: C. initiate sepsis-focused assessment and notify the provider/rapid
response while obtaining ordered cultures and lactate
Rationale: Hypotension and altered mentation with infection suggest organ dysfunction from
sepsis. Early recognition and prompt treatment, including cultures, lactate, fluids, and
antimicrobials as ordered, improve outcomes. Nonurgent comfort measures should not delay
stabilization.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Analyze cues; Take action
6. During morning assessment, a nurse notes muscle weakness with peaked T waves
on ECG in a client being treated for hyperkalemia. Which action should the nurse take
first?
A. Provide routine comfort measures before further assessment
B. Document the findings and reassess at the end of the shift
C. place the client on cardiac monitoring and notify the provider for urgent treatment
D. Delay intervention until all scheduled medications have been administered
Correct Answer: C. place the client on cardiac monitoring and notify the provider for
urgent treatment
Rationale: Peaked T waves indicate cardiac effects of hyperkalemia and risk for lethal
dysrhythmias. Continuous monitoring and rapid treatment are priorities. Dietary teaching is
important later but does not address the immediate threat.
NCLEX Client Need: Reduction of Risk Potential
Clinical Judgment Focus: Prioritize hypotheses; Take action
7. During morning assessment, a nurse notes severe dyspnea, unilateral absent breath
sounds, hypotension, tracheal deviation in a client being treated for tension
pneumothorax. Which action should the nurse take first?
A. Provide routine comfort measures before further assessment
B. Delay intervention until all scheduled medications have been administered
C. Document the findings and reassess at the end of the shift
, D. call for emergency assistance and prepare for immediate decompression
Correct Answer: D. call for emergency assistance and prepare for immediate
decompression
Rationale: These findings indicate tension pneumothorax with obstructive shock. The client
can deteriorate rapidly, so emergency decompression is required. Waiting for routine imaging
before escalation is unsafe in an unstable client.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Recognize cues; Take action
8. During morning assessment, a nurse notes wheezing, facial swelling, hypotension
after medication in a client being treated for anaphylaxis. Which action should the nurse
take first?
A. administer IM epinephrine promptly and support airway/breathing
B. Provide routine comfort measures before further assessment
C. Document the findings and reassess at the end of the shift
D. Delay intervention until all scheduled medications have been administered
Correct Answer: A. administer IM epinephrine promptly and support airway/breathing
Rationale: Anaphylaxis threatens airway and circulation. Intramuscular epinephrine is the first-
line treatment because it reverses bronchospasm and vasodilation. Antihistamines are
adjuncts and should not delay epinephrine.
NCLEX Client Need: Physiological Adaptation
Clinical Judgment Focus: Take action; Evaluate outcomes
9. During morning assessment, a nurse notes polyuria, dehydration, abdominal pain,
Kussmaul respirations, high glucose in a client being treated for DKA. Which action
should the nurse take first?
A. Document the findings and reassess at the end of the shift
B. Delay intervention until all scheduled medications have been administered
C. Provide routine comfort measures before further assessment
D. begin isotonic IV fluids and follow the DKA protocol
Correct Answer: D. begin isotonic IV fluids and follow the DKA protocol
Rationale: DKA causes severe volume depletion and metabolic acidosis. Initial isotonic fluid
resuscitation restores perfusion; insulin and electrolyte management follow according to
