LPN/LVN NCLEX-PN Comprehensive Study Guide Exam 2 2026 UPDATE
|SBON
1. A nurse is caring for a patient who is 24 hours postoperative following
abdominal surgery. Which of the following findings should the nurse report to
the provider immediately?
A. A blood pressure of 118/72 mmHg
B. Reporting pain as 5 on a scale of 0 to 10
C. Serosanguineous drainage on the surgical dressing
D. A urine output of 20 mL per hour for two consecutive hours
Answer: D
Rationale: A urine output of less than 30 mL/hr is a sign of decreased renal perfusion or
potential shock and must be reported immediately.
2. Which of the following interventions is most important for a nurse to
implement for a patient with a diagnosis of deep vein thrombosis (DVT)?
A. Apply sequential compression devices to both legs
B. Massage the affected extremity to improve circulation
C. Maintain the patient on bed rest with the affected limb elevated
D. Perform vigorous range-of-motion exercises every 2 hours
Answer: C
Rationale: Bed rest and elevation of the affected limb help reduce edema and prevent the
dislodgement of the clot; massaging the limb is contraindicated as it can cause an
embolism.
,3. A nurse is preparing to administer digoxin to a patient. Which of the following
assessments should the nurse perform first?
A. Check the patient’s blood pressure
B. Assess the patient’s weight
C. Evaluate the patient’s respiratory rate
D. Measure the patient’s apical pulse for 1 full minute
Answer: D
Rationale: Digoxin should be withheld if the apical pulse is less than 60 bpm in adults, as it
can cause bradycardia.
4. A patient with Type 1 Diabetes Mellitus is found sweaty, shaky, and confused.
What is the nurse’s priority action?
A. Administer the scheduled dose of regular insulin
B. Call the provider to request a STAT blood glucose test
C. Administer 15g of fast-acting carbohydrates
D. Provide a high-protein snack like peanut butter
Answer: C
Rationale: The patient is showing signs of hypoglycemia. The immediate priority is to raise
the blood glucose level with fast-acting carbohydrates.
5. Which precaution should the nurse implement for a patient diagnosed with
Pulmonary Tuberculosis?
A. Standard precautions only
B. Droplet precautions
C. Contact precautions
D. Airborne precautions
Answer: D
Rationale: Tuberculosis is transmitted via small droplets that remain suspended in the air,
requiring an N95 respirator and a negative-pressure room.
, 6. A nurse is teaching a patient about a new prescription for warfarin. Which of
the following statements indicates an understanding of the teaching?
A. I will use a soft-bristled toothbrush to brush my teeth
B. I should increase my intake of spinach and kale
C. I can take aspirin if I have a headache
D. I will stop taking the medication if I see bruising
Answer: A
Rationale: Warfarin increases the risk of bleeding; using a soft-bristled toothbrush helps
prevent gum trauma and bleeding.
7. A nurse is caring for a patient who is in the first stage of labor. The nurse
notes the fetal heart rate is 140/min with moderate variability. Which of the
following actions should the nurse take?
A. Prepare for an emergency cesarean section
B. Continue to monitor the patient as these are normal findings
C. Administer oxygen via non-rebreather mask
D. Turn the patient onto her right side
Answer: B
Rationale: A fetal heart rate of 110-160/min with moderate variability is a reassuring sign
of fetal well-being.
8. What is the correct technique for administering ear drops to an adult patient?
A. Pull the pinna down and back
B. Hold the pinna forward
C. Pull the pinna straight back
D. Pull the pinna up and back
Answer: D
Rationale: For adults, the pinna is pulled up and back to straighten the ear canal; for
children under 3, it is pulled down and back.
|SBON
1. A nurse is caring for a patient who is 24 hours postoperative following
abdominal surgery. Which of the following findings should the nurse report to
the provider immediately?
A. A blood pressure of 118/72 mmHg
B. Reporting pain as 5 on a scale of 0 to 10
C. Serosanguineous drainage on the surgical dressing
D. A urine output of 20 mL per hour for two consecutive hours
Answer: D
Rationale: A urine output of less than 30 mL/hr is a sign of decreased renal perfusion or
potential shock and must be reported immediately.
2. Which of the following interventions is most important for a nurse to
implement for a patient with a diagnosis of deep vein thrombosis (DVT)?
A. Apply sequential compression devices to both legs
B. Massage the affected extremity to improve circulation
C. Maintain the patient on bed rest with the affected limb elevated
D. Perform vigorous range-of-motion exercises every 2 hours
Answer: C
Rationale: Bed rest and elevation of the affected limb help reduce edema and prevent the
dislodgement of the clot; massaging the limb is contraindicated as it can cause an
embolism.
,3. A nurse is preparing to administer digoxin to a patient. Which of the following
assessments should the nurse perform first?
A. Check the patient’s blood pressure
B. Assess the patient’s weight
C. Evaluate the patient’s respiratory rate
D. Measure the patient’s apical pulse for 1 full minute
Answer: D
Rationale: Digoxin should be withheld if the apical pulse is less than 60 bpm in adults, as it
can cause bradycardia.
4. A patient with Type 1 Diabetes Mellitus is found sweaty, shaky, and confused.
What is the nurse’s priority action?
A. Administer the scheduled dose of regular insulin
B. Call the provider to request a STAT blood glucose test
C. Administer 15g of fast-acting carbohydrates
D. Provide a high-protein snack like peanut butter
Answer: C
Rationale: The patient is showing signs of hypoglycemia. The immediate priority is to raise
the blood glucose level with fast-acting carbohydrates.
5. Which precaution should the nurse implement for a patient diagnosed with
Pulmonary Tuberculosis?
A. Standard precautions only
B. Droplet precautions
C. Contact precautions
D. Airborne precautions
Answer: D
Rationale: Tuberculosis is transmitted via small droplets that remain suspended in the air,
requiring an N95 respirator and a negative-pressure room.
, 6. A nurse is teaching a patient about a new prescription for warfarin. Which of
the following statements indicates an understanding of the teaching?
A. I will use a soft-bristled toothbrush to brush my teeth
B. I should increase my intake of spinach and kale
C. I can take aspirin if I have a headache
D. I will stop taking the medication if I see bruising
Answer: A
Rationale: Warfarin increases the risk of bleeding; using a soft-bristled toothbrush helps
prevent gum trauma and bleeding.
7. A nurse is caring for a patient who is in the first stage of labor. The nurse
notes the fetal heart rate is 140/min with moderate variability. Which of the
following actions should the nurse take?
A. Prepare for an emergency cesarean section
B. Continue to monitor the patient as these are normal findings
C. Administer oxygen via non-rebreather mask
D. Turn the patient onto her right side
Answer: B
Rationale: A fetal heart rate of 110-160/min with moderate variability is a reassuring sign
of fetal well-being.
8. What is the correct technique for administering ear drops to an adult patient?
A. Pull the pinna down and back
B. Hold the pinna forward
C. Pull the pinna straight back
D. Pull the pinna up and back
Answer: D
Rationale: For adults, the pinna is pulled up and back to straighten the ear canal; for
children under 3, it is pulled down and back.
