NCLEX-RN PRACTICE EXAM 2025-2026
COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+||BRAND NEW
VERSION!!
1. A nurse is caring for a client with heart failure who is receiving
furosemide. Which finding requires immediate intervention?
A. Urine output of 40 mL/hr
B. Blood pressure 128/76 mmHg
C. Potassium level 2.9 mEq/L ✔
D. Weight loss of 1 lb in 24 hours
Rationale: Hypokalemia is a serious adverse effect of loop diuretics
and can cause life-threatening dysrhythmias.
2. A client with diabetes mellitus reports shakiness and diaphoresis.
Which action should the nurse take first?
A. Administer insulin
B. Notify the provider
C. Check blood glucose ✔
D. Give oral fluids
Rationale: Symptoms suggest hypoglycemia; blood glucose must
be checked immediately to confirm.
3. The nurse is teaching a client about deep vein thrombosis
prevention. Which statement indicates understanding?
A. “I will sit with my legs crossed.”
B. “I will massage my calves daily.”
, C. “I will ambulate as soon as possible.” ✔
D. “I will limit my fluid intake.”
Rationale: Early ambulation promotes venous return and prevents
clot formation.
4. A postoperative client reports severe pain unrelieved by
prescribed medication. What is the nurse’s priority action?
A. Reposition the client
B. Document the finding
C. Notify the provider ✔
D. Reassess pain in 30 minutes
Rationale: Severe unrelieved pain may indicate complications and
requires provider notification.
5. Which assessment finding is expected in a client with left-sided
heart failure?
A. Peripheral edema
B. Ascites
C. Crackles in lungs ✔
D. Jugular vein distention
Rationale: Left-sided heart failure causes pulmonary congestion
and crackles.
6. A client receiving morphine develops respiratory depression.
Which medication should the nurse prepare?
A. Naloxone
B. Protamine sulfate
C. Vitamin K
D. Flumazenil
A. Naloxone ✔
, Rationale: Naloxone reverses opioid-induced respiratory
depression.
7. The nurse is caring for a client with a chest tube. Which finding
requires immediate intervention?
A. Continuous bubbling in suction chamber
B. Tidaling in the water-seal chamber
C. Chest tube disconnected from drainage system ✔
D. Drainage of 50 mL in 8 hours
Rationale: Disconnection can lead to pneumothorax and requires
immediate action.
8. A client is at risk for aspiration. Which nursing intervention is most
appropriate?
A. Encourage fluids at bedtime
B. Keep the head of bed elevated during meals ✔
C. Place the client supine
D. Use thin liquids
Rationale: Elevating the head of the bed reduces aspiration risk.
9. A nurse is caring for a client with suspected stroke. Which action
should be taken first?
A. Check blood glucose
B. Administer aspirin
C. Assess airway and breathing ✔
D. Obtain history
Rationale: Airway and breathing are priority according to ABCs.
10. Which finding indicates effective treatment of pneumonia?
A. Increased WBC count
B. Productive cough
COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+||BRAND NEW
VERSION!!
1. A nurse is caring for a client with heart failure who is receiving
furosemide. Which finding requires immediate intervention?
A. Urine output of 40 mL/hr
B. Blood pressure 128/76 mmHg
C. Potassium level 2.9 mEq/L ✔
D. Weight loss of 1 lb in 24 hours
Rationale: Hypokalemia is a serious adverse effect of loop diuretics
and can cause life-threatening dysrhythmias.
2. A client with diabetes mellitus reports shakiness and diaphoresis.
Which action should the nurse take first?
A. Administer insulin
B. Notify the provider
C. Check blood glucose ✔
D. Give oral fluids
Rationale: Symptoms suggest hypoglycemia; blood glucose must
be checked immediately to confirm.
3. The nurse is teaching a client about deep vein thrombosis
prevention. Which statement indicates understanding?
A. “I will sit with my legs crossed.”
B. “I will massage my calves daily.”
, C. “I will ambulate as soon as possible.” ✔
D. “I will limit my fluid intake.”
Rationale: Early ambulation promotes venous return and prevents
clot formation.
4. A postoperative client reports severe pain unrelieved by
prescribed medication. What is the nurse’s priority action?
A. Reposition the client
B. Document the finding
C. Notify the provider ✔
D. Reassess pain in 30 minutes
Rationale: Severe unrelieved pain may indicate complications and
requires provider notification.
5. Which assessment finding is expected in a client with left-sided
heart failure?
A. Peripheral edema
B. Ascites
C. Crackles in lungs ✔
D. Jugular vein distention
Rationale: Left-sided heart failure causes pulmonary congestion
and crackles.
6. A client receiving morphine develops respiratory depression.
Which medication should the nurse prepare?
A. Naloxone
B. Protamine sulfate
C. Vitamin K
D. Flumazenil
A. Naloxone ✔
, Rationale: Naloxone reverses opioid-induced respiratory
depression.
7. The nurse is caring for a client with a chest tube. Which finding
requires immediate intervention?
A. Continuous bubbling in suction chamber
B. Tidaling in the water-seal chamber
C. Chest tube disconnected from drainage system ✔
D. Drainage of 50 mL in 8 hours
Rationale: Disconnection can lead to pneumothorax and requires
immediate action.
8. A client is at risk for aspiration. Which nursing intervention is most
appropriate?
A. Encourage fluids at bedtime
B. Keep the head of bed elevated during meals ✔
C. Place the client supine
D. Use thin liquids
Rationale: Elevating the head of the bed reduces aspiration risk.
9. A nurse is caring for a client with suspected stroke. Which action
should be taken first?
A. Check blood glucose
B. Administer aspirin
C. Assess airway and breathing ✔
D. Obtain history
Rationale: Airway and breathing are priority according to ABCs.
10. Which finding indicates effective treatment of pneumonia?
A. Increased WBC count
B. Productive cough
