Adult Health CJE Exam Newest Questions
with Answers and Detailed Rationales |
NCLEX-Style Review Test 2026 | instant
pdf download
1. A patient with chronic heart failure is admitted with increasing shortness of breath.
Vital signs: BP 168/92, HR 112, RR 28, SpO₂ 88% on room air. What is the nurse’s
priority action?
A. Administer oral furosemide
B. Place patient in high-Fowler’s position and apply oxygen
C. Obtain a full set of lab values
D. Encourage deep breathing and coughing
Answer: B
Rationale:
This patient shows acute hypoxemia and respiratory distress. The priority is ABCs
(Airway/Breathing first). High-Fowler’s position improves lung expansion and oxygen is
immediately required. Diuretics and labs are important but not first.
2. A post-op patient suddenly becomes restless, tachycardic, and complains of sharp
chest pain. The nurse suspects pulmonary embolism. What is the next best action?
A. Encourage coughing and deep breathing
B. Raise the head of bed and administer oxygen
C. Obtain a chest X-ray
D. Prepare for discharge teaching
Answer: B
,Rationale:
PE is a life-threatening obstruction of pulmonary blood flow. Immediate oxygenation
and positioning are priority. Diagnostic tests come after stabilization.
3. A patient receiving morphine develops a respiratory rate of 8/min and is difficult to
arouse. What is the priority intervention?
A. Stimulate the patient and reassess in 15 minutes
B. Prepare naloxone administration
C. Encourage oral fluids
D. Document findings
Answer: B
Rationale:
This indicates opioid-induced respiratory depression, a medical emergency. Naloxone
(opioid antagonist) reverses effects immediately.
4. A patient with diabetes has blood glucose of 42 mg/dL and is unconscious. What
should the nurse do first?
A. Give oral glucose gel
B. Administer IV dextrose
C. Recheck glucose
D. Give insulin
Answer: B
Rationale:
Unconscious patient = cannot swallow safely. IV dextrose is the fastest and safest
correction.
5. A patient with COPD is receiving oxygen therapy. Which finding indicates effective
treatment?
,A. PaO₂ increased from 55 to 70 mmHg
B. Respiratory rate increases to 32
C. Cyanosis worsens
D. Confusion increases
Answer: A
Rationale:
Improved oxygenation (PaO₂ rise) indicates therapy effectiveness. COPD patients need
controlled oxygen but still require adequate oxygenation.
6. A patient with hyperkalemia (K⁺ = 6.9 mEq/L) shows peaked T waves on ECG. What
is the nurse’s priority action?
A. Give potassium supplement
B. Prepare calcium gluconate administration
C. Restrict fluids
D. Encourage exercise
Answer: B
Rationale:
Calcium gluconate stabilizes cardiac membranes and prevents lethal dysrhythmias. This
is an emergency ECG finding.
7. A patient with stroke has right-sided weakness and difficulty speaking. What is the
priority nursing action?
A. Provide a high-protein diet
B. Maintain airway and assess swallowing ability
C. Encourage active range of motion immediately
D. Place patient in Trendelenburg position
Answer: B
, Rationale:
Stroke patients are at high risk for aspiration and airway compromise. Swallow evaluation
and airway safety come first.
8. A patient with acute kidney injury has urine output of 15 mL/hr. What is the most
important nursing action?
A. Encourage increased oral fluids
B. Assess for fluid overload and notify provider
C. Restrict all protein intake
D. Document as normal
Answer: B
Rationale:
Oliguria (<30 mL/hr) suggests worsening renal function and possible fluid imbalance.
9. A patient on heparin therapy has a sudden drop in platelet count. What
complication is suspected?
A. Anemia
B. Heparin-induced thrombocytopenia (HIT)
C. Infection
D. Hypertension
Answer: B
Rationale:
HIT is a serious immune reaction causing low platelets and increased clot risk,
paradoxically dangerous.
10. A patient with pneumonia has oxygen saturation of 90% and thick secretions.
What is the priority intervention?
with Answers and Detailed Rationales |
NCLEX-Style Review Test 2026 | instant
pdf download
1. A patient with chronic heart failure is admitted with increasing shortness of breath.
Vital signs: BP 168/92, HR 112, RR 28, SpO₂ 88% on room air. What is the nurse’s
priority action?
A. Administer oral furosemide
B. Place patient in high-Fowler’s position and apply oxygen
C. Obtain a full set of lab values
D. Encourage deep breathing and coughing
Answer: B
Rationale:
This patient shows acute hypoxemia and respiratory distress. The priority is ABCs
(Airway/Breathing first). High-Fowler’s position improves lung expansion and oxygen is
immediately required. Diuretics and labs are important but not first.
2. A post-op patient suddenly becomes restless, tachycardic, and complains of sharp
chest pain. The nurse suspects pulmonary embolism. What is the next best action?
A. Encourage coughing and deep breathing
B. Raise the head of bed and administer oxygen
C. Obtain a chest X-ray
D. Prepare for discharge teaching
Answer: B
,Rationale:
PE is a life-threatening obstruction of pulmonary blood flow. Immediate oxygenation
and positioning are priority. Diagnostic tests come after stabilization.
3. A patient receiving morphine develops a respiratory rate of 8/min and is difficult to
arouse. What is the priority intervention?
A. Stimulate the patient and reassess in 15 minutes
B. Prepare naloxone administration
C. Encourage oral fluids
D. Document findings
Answer: B
Rationale:
This indicates opioid-induced respiratory depression, a medical emergency. Naloxone
(opioid antagonist) reverses effects immediately.
4. A patient with diabetes has blood glucose of 42 mg/dL and is unconscious. What
should the nurse do first?
A. Give oral glucose gel
B. Administer IV dextrose
C. Recheck glucose
D. Give insulin
Answer: B
Rationale:
Unconscious patient = cannot swallow safely. IV dextrose is the fastest and safest
correction.
5. A patient with COPD is receiving oxygen therapy. Which finding indicates effective
treatment?
,A. PaO₂ increased from 55 to 70 mmHg
B. Respiratory rate increases to 32
C. Cyanosis worsens
D. Confusion increases
Answer: A
Rationale:
Improved oxygenation (PaO₂ rise) indicates therapy effectiveness. COPD patients need
controlled oxygen but still require adequate oxygenation.
6. A patient with hyperkalemia (K⁺ = 6.9 mEq/L) shows peaked T waves on ECG. What
is the nurse’s priority action?
A. Give potassium supplement
B. Prepare calcium gluconate administration
C. Restrict fluids
D. Encourage exercise
Answer: B
Rationale:
Calcium gluconate stabilizes cardiac membranes and prevents lethal dysrhythmias. This
is an emergency ECG finding.
7. A patient with stroke has right-sided weakness and difficulty speaking. What is the
priority nursing action?
A. Provide a high-protein diet
B. Maintain airway and assess swallowing ability
C. Encourage active range of motion immediately
D. Place patient in Trendelenburg position
Answer: B
, Rationale:
Stroke patients are at high risk for aspiration and airway compromise. Swallow evaluation
and airway safety come first.
8. A patient with acute kidney injury has urine output of 15 mL/hr. What is the most
important nursing action?
A. Encourage increased oral fluids
B. Assess for fluid overload and notify provider
C. Restrict all protein intake
D. Document as normal
Answer: B
Rationale:
Oliguria (<30 mL/hr) suggests worsening renal function and possible fluid imbalance.
9. A patient on heparin therapy has a sudden drop in platelet count. What
complication is suspected?
A. Anemia
B. Heparin-induced thrombocytopenia (HIT)
C. Infection
D. Hypertension
Answer: B
Rationale:
HIT is a serious immune reaction causing low platelets and increased clot risk,
paradoxically dangerous.
10. A patient with pneumonia has oxygen saturation of 90% and thick secretions.
What is the priority intervention?
