1|Page
SAUNDERS NCLEX RN PRACTICE
EXAM 2026 ALL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES ALREADY A GRADED
|NEW AND REVISED
A client who has been receiving total parenteral nutrition (TPN) by way
of a central venous access device complains of chest pain and dyspnea.
The nurse quickly assesses the client's vital signs and notes that the pulse
rate has increased and the blood pressure has dropped. The nurse
determines that the client is most likely experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - ANSWER- 2-Air embolism
The signs and symptoms of air embolism include chest pain,
dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse
also may hear a loud churning sound over the pericardium on
auscultation of the client's chest. The signs and symptoms of sepsis
include fever, chills, and general malaise. Fluid overload causes
increased intravascular volume, which increases the blood pressure
and the pulse rate as the heart tries to pump the extra fluid volume.
Fluid overload also causes neck vein distention and shifting of fluid
into the alveoli, resulting in lung crackles. The signs and symptoms
,2|Page
of a fluid imbalance depend on the type of imbalance the client is
experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of
burning and a feeling of tightness at the IV insertion site. On assessment,
the nurse detects coolness and swelling at the site and notes that the IV
rate has slowed. The nurse determines that which complication has
occurred? - ANSWER- 1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
An infiltrated IV line is one that has dislodged from the vein and is
lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV
site result when IV fluid is deposited in the subcutaneous tissue.
When the pressure in the tissues exceeds the pressure in the tubing,
the flow of IV solution will slow down or stop. The corrective action
is to remove the catheter and start a new IV line at another site. The
conditions identified in options 1, 2, and 4 are likely to be
accompanied by warmth at the site, not coolness.
A nurse provides instructions to a preoperative client about the use of an
incentive spirometer. The nurse determines that the client needs further
instruction if the client indicates that he or she will take which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
,3|Page
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then
exhale. - ANSWER- 4-After maximal inspiration, hold the breath for 10
seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client
should assume a semi-Fowler's or high Fowler's position. The
mouthpiece should be covered completely and tightly while the
client inhales slowly, with a constant flow through the unit. When
maximal inspiration is reached, the client should hold the breath for
2 or 3 seconds and then exhale slowly
The nurse is monitoring a client who has a closed chest tube drainage
system. The nurse notes fluctuation of the fluid level in the water-seal
chamber during inspiration and expiration. On the basis of this finding,
the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. -
ANSWER- 2-The chest tube is functioning as expected.
The presence of fluctuation of the fluid level in the water-seal
chamber indicates a patent drainage system. With normal
breathing, the water level rises with inspiration and falls with
expiration. Fluctuation stops if the tube is obstructed, if the suction
, 4|Page
is not working properly, or if the lung has re-expanded. Options 1,
3, and 4 are incorrect interpretations of the finding. An air leak may
cause excessive bubbling in the water seal chamber. Excessive and
vigorous bubbling in the suction control chamber may indicate that
the amount of suction needs to be decreased. The status of the
dressing is not specifically related to the presence of fluctuation of
the fluid level in the water-seal chamber
A nurse is providing morning care to a client who has a closed chest
tube drainage system to treat a pneumothorax. When the nurse turns the
client to the side, the chest tube is accidentally dislodged from the chest.
The nurse immediately applies sterile gauze over the chest tube insertion
site. Which is the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - ANSWER- 1-Call the
health care provider.
If the chest drainage system is dislodged from the insertion site, the
nurse immediately applies sterile gauze over the site and calls the
health care provider. The nurse would maintain the client in an
upright position. A new chest tube system may be attached if the
tube requires insertion, but this would not be the next action. Pulse
oximetry readings would assist in determining the client's
SAUNDERS NCLEX RN PRACTICE
EXAM 2026 ALL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES ALREADY A GRADED
|NEW AND REVISED
A client who has been receiving total parenteral nutrition (TPN) by way
of a central venous access device complains of chest pain and dyspnea.
The nurse quickly assesses the client's vital signs and notes that the pulse
rate has increased and the blood pressure has dropped. The nurse
determines that the client is most likely experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - ANSWER- 2-Air embolism
The signs and symptoms of air embolism include chest pain,
dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse
also may hear a loud churning sound over the pericardium on
auscultation of the client's chest. The signs and symptoms of sepsis
include fever, chills, and general malaise. Fluid overload causes
increased intravascular volume, which increases the blood pressure
and the pulse rate as the heart tries to pump the extra fluid volume.
Fluid overload also causes neck vein distention and shifting of fluid
into the alveoli, resulting in lung crackles. The signs and symptoms
,2|Page
of a fluid imbalance depend on the type of imbalance the client is
experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of
burning and a feeling of tightness at the IV insertion site. On assessment,
the nurse detects coolness and swelling at the site and notes that the IV
rate has slowed. The nurse determines that which complication has
occurred? - ANSWER- 1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
An infiltrated IV line is one that has dislodged from the vein and is
lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV
site result when IV fluid is deposited in the subcutaneous tissue.
When the pressure in the tissues exceeds the pressure in the tubing,
the flow of IV solution will slow down or stop. The corrective action
is to remove the catheter and start a new IV line at another site. The
conditions identified in options 1, 2, and 4 are likely to be
accompanied by warmth at the site, not coolness.
A nurse provides instructions to a preoperative client about the use of an
incentive spirometer. The nurse determines that the client needs further
instruction if the client indicates that he or she will take which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
,3|Page
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then
exhale. - ANSWER- 4-After maximal inspiration, hold the breath for 10
seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client
should assume a semi-Fowler's or high Fowler's position. The
mouthpiece should be covered completely and tightly while the
client inhales slowly, with a constant flow through the unit. When
maximal inspiration is reached, the client should hold the breath for
2 or 3 seconds and then exhale slowly
The nurse is monitoring a client who has a closed chest tube drainage
system. The nurse notes fluctuation of the fluid level in the water-seal
chamber during inspiration and expiration. On the basis of this finding,
the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. -
ANSWER- 2-The chest tube is functioning as expected.
The presence of fluctuation of the fluid level in the water-seal
chamber indicates a patent drainage system. With normal
breathing, the water level rises with inspiration and falls with
expiration. Fluctuation stops if the tube is obstructed, if the suction
, 4|Page
is not working properly, or if the lung has re-expanded. Options 1,
3, and 4 are incorrect interpretations of the finding. An air leak may
cause excessive bubbling in the water seal chamber. Excessive and
vigorous bubbling in the suction control chamber may indicate that
the amount of suction needs to be decreased. The status of the
dressing is not specifically related to the presence of fluctuation of
the fluid level in the water-seal chamber
A nurse is providing morning care to a client who has a closed chest
tube drainage system to treat a pneumothorax. When the nurse turns the
client to the side, the chest tube is accidentally dislodged from the chest.
The nurse immediately applies sterile gauze over the chest tube insertion
site. Which is the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - ANSWER- 1-Call the
health care provider.
If the chest drainage system is dislodged from the insertion site, the
nurse immediately applies sterile gauze over the site and calls the
health care provider. The nurse would maintain the client in an
upright position. A new chest tube system may be attached if the
tube requires insertion, but this would not be the next action. Pulse
oximetry readings would assist in determining the client's
