NCLEX EXAM zm
Exam Solution zm
Saunders NCLEX Questions 2026 A+ GRADE ASSURED C zm zm zm zm zm zm zm
OMPLETE SOLUTIONS AND VERIFIED ANSWERS (25C2 zm zm zm zm zm
8)
QUESTION 1 zm
The nurse caring for a client with a chest tube turns the client to the side and the che
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st tube accidentally disconnects from the water seal chamber. Which initial nursing ac
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tion should the nurse take? 1. Call the health care provider (HCP). 2. Place the tube in
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a bottle of sterile water. 3. Replace the chest tube system. 4. Place a sterile dressing
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over the disconnection site.
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ANSWER
2. Place the tube in a bottle of sterile water. If the chest drainage system is disconnected, the end o
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f the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need
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to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if th
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e collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent co
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mplications resulting from the disconnection. zm zm zm zm
QUESTION 2 zm
The nurse is assisting a health care provider with the removal of a chest tube. The nu
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rse should instruct the client to take which action? 1. Exhale slowly. 2. Stay very still.
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3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.
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ANSWER
4. Perform the Valsalva maneuver. When the chest tube is removed, the client is asked to perform t
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he Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn,
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and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a de
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ep breath and hold the breath while the tube is removed.
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QUESTION 3 zm
While changing the tapes on a tracheostomy tube, the client coughs and the tube is di
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slodged. Which is the initial nursing action? 1. Call the health care provider to reinser
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,t the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respirator
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y therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site wit
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h a sterile dressing to prevent infection.
zm zm zm zm zm zm
ANSWER
2. Grasp the retention sutures to spread the opening. If the tube is dislodged accidentally, the initial
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mnursing action is to grasp the retention sutures and spread the opening. If agency policy permits, th
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e nurse then attempts immediately to replace the tube. Calling ancillary services or the HCP will del
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ay treatment in this emergency situation. Covering the tracheostomy site will block the airway.
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QUESTION 4 zm
The nurse is caring for a client immediately after removal of the endotracheal tube. T
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he nurse should report which sign immediately if experienced by the client? 1. Stridor
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2. Occasional pink-
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tinged sputum 3. Respiratory rate of 24 breaths/minute 4. A few basilar lung crackles
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mon the right zm zm
ANSWER
1. Stridor Following removal of the endotracheal tube the nurse monitors the client for respiratory
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distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-
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pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway e
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dema and places the client at risk for airway obstruction. Although the findings identified in the re
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
maining options require monitoring, they do not require immediate notification of the health care pr
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ovider.
QUESTION 5 zm
The emergency department nurse is assessing a client who has sustained a blunt injur
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y to the chest wall. Which finding would indicate the presence of a pneumothorax in t
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
his client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a
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barrel chest 4. A sucking sound at the site of injury
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ANSWER
2 This client has sustained a blunt or closed-
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chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A la
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rger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous em
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physema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury
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would be noted with an open chest injury.
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QUESTION 6 zm
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should
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plan to limit the suctioning time to a maximum of which time period? 1. 1 minute 2.
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5 seconds 3. 10 seconds 4. 30 seconds
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, ANSWER
3. 10 seconds Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker ce
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lls in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate
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mthe client before suctioning and limit the suctioning pass to 10 seconds.
zm zm zm zm zm zm zm zm zm zm zm
QUESTION 7 zm
A client with a chest injury has suffered flail chest. The nurse assesses the client for
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which most distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical ch
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est movement 4. Dyspnea, especially on exhalation
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ANSWER
3 Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because t
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his section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest
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movement. This means that the force of inspiration pulls the fractured segment inward, while the re
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st of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of
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mthe chest moves inward. This is a characteristic sign of flail chest.
zm zm zm zm zm zm zm zm zm zm zm
QUESTION 8 zm
The nurse is assessing a client with multiple trauma who is at risk for developing acu
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te respiratory distress syndrome. The nurse should assess for which earliest sign of a
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cute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Int
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ercostal retractions 4. Increased respiratory rate
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ANSWER
4 The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate
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, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasi
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ng dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear o
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
r consist of fine inspiratory crackles or diffuse coarse crackles.
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QUESTION 9 zm
A client has experienced pulmonary embolism. The nurse should assess for which sym
zm zm zm zm zm zm zm zm zm zm zm zm
ptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and f
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ever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken
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ANSWER
3 The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset.
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The next most commonly reported symptom is dyspnea, which is accompanied by an increased respi
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ratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, t
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achycardia, cough, and cyanosis. zm zm zm
QUESTION 10 zm
Exam Solution zm
Saunders NCLEX Questions 2026 A+ GRADE ASSURED C zm zm zm zm zm zm zm
OMPLETE SOLUTIONS AND VERIFIED ANSWERS (25C2 zm zm zm zm zm
8)
QUESTION 1 zm
The nurse caring for a client with a chest tube turns the client to the side and the che
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
st tube accidentally disconnects from the water seal chamber. Which initial nursing ac
zm zm zm zm zm zm zm zm zm zm zm zm
tion should the nurse take? 1. Call the health care provider (HCP). 2. Place the tube in
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
a bottle of sterile water. 3. Replace the chest tube system. 4. Place a sterile dressing
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over the disconnection site.
zm zm zm
ANSWER
2. Place the tube in a bottle of sterile water. If the chest drainage system is disconnected, the end o
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
f the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need
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to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if th
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent co
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mplications resulting from the disconnection. zm zm zm zm
QUESTION 2 zm
The nurse is assisting a health care provider with the removal of a chest tube. The nu
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rse should instruct the client to take which action? 1. Exhale slowly. 2. Stay very still.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.
zm zm zm zm zm zm zm zm zm
ANSWER
4. Perform the Valsalva maneuver. When the chest tube is removed, the client is asked to perform t
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
he Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn,
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a de
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ep breath and hold the breath while the tube is removed.
zm zm zm zm zm zm zm zm zm zm
QUESTION 3 zm
While changing the tapes on a tracheostomy tube, the client coughs and the tube is di
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
slodged. Which is the initial nursing action? 1. Call the health care provider to reinser
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
,t the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respirator
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
y therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site wit
zm zm zm zm zm zm zm zm zm zm zm zm
h a sterile dressing to prevent infection.
zm zm zm zm zm zm
ANSWER
2. Grasp the retention sutures to spread the opening. If the tube is dislodged accidentally, the initial
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mnursing action is to grasp the retention sutures and spread the opening. If agency policy permits, th
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e nurse then attempts immediately to replace the tube. Calling ancillary services or the HCP will del
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ay treatment in this emergency situation. Covering the tracheostomy site will block the airway.
zm zm zm zm zm zm zm zm zm zm zm zm zm
QUESTION 4 zm
The nurse is caring for a client immediately after removal of the endotracheal tube. T
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he nurse should report which sign immediately if experienced by the client? 1. Stridor
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2. Occasional pink-
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tinged sputum 3. Respiratory rate of 24 breaths/minute 4. A few basilar lung crackles
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mon the right zm zm
ANSWER
1. Stridor Following removal of the endotracheal tube the nurse monitors the client for respiratory
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway e
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
dema and places the client at risk for airway obstruction. Although the findings identified in the re
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
maining options require monitoring, they do not require immediate notification of the health care pr
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ovider.
QUESTION 5 zm
The emergency department nurse is assessing a client who has sustained a blunt injur
zm zm zm zm zm zm zm zm zm zm zm zm zm
y to the chest wall. Which finding would indicate the presence of a pneumothorax in t
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
his client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
barrel chest 4. A sucking sound at the site of injury
zm zm zm zm zm zm zm zm zm zm
ANSWER
2 This client has sustained a blunt or closed-
zm zm zm zm zm zm zm zm
chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A la
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
rger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous em
zm zm zm zm zm zm zm zm zm zm zm
physema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
would be noted with an open chest injury.
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QUESTION 6 zm
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
plan to limit the suctioning time to a maximum of which time period? 1. 1 minute 2.
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5 seconds 3. 10 seconds 4. 30 seconds
zm zm zm zm zm zm zm
, ANSWER
3. 10 seconds Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker ce
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
lls in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate
zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mthe client before suctioning and limit the suctioning pass to 10 seconds.
zm zm zm zm zm zm zm zm zm zm zm
QUESTION 7 zm
A client with a chest injury has suffered flail chest. The nurse assesses the client for
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
which most distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical ch
zm zm zm zm zm zm zm zm zm zm zm zm zm
est movement 4. Dyspnea, especially on exhalation
zm zm zm zm zm zm
ANSWER
3 Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because t
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
his section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
movement. This means that the force of inspiration pulls the fractured segment inward, while the re
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
st of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mthe chest moves inward. This is a characteristic sign of flail chest.
zm zm zm zm zm zm zm zm zm zm zm
QUESTION 8 zm
The nurse is assessing a client with multiple trauma who is at risk for developing acu
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
te respiratory distress syndrome. The nurse should assess for which earliest sign of a
zm zm zm zm zm zm zm zm zm zm zm zm zm
cute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Int
zm zm zm zm zm zm zm zm zm zm zm
ercostal retractions 4. Increased respiratory rate
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ANSWER
4 The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasi
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ng dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear o
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
r consist of fine inspiratory crackles or diffuse coarse crackles.
zm zm zm zm zm zm zm zm zm
QUESTION 9 zm
A client has experienced pulmonary embolism. The nurse should assess for which sym
zm zm zm zm zm zm zm zm zm zm zm zm
ptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and f
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken
zm zm zm zm zm zm zm zm zm zm zm zm zm
ANSWER
3 The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
The next most commonly reported symptom is dyspnea, which is accompanied by an increased respi
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, t
zm zm zm zm zm zm zm zm zm zm zm zm
achycardia, cough, and cyanosis. zm zm zm
QUESTION 10 zm
