NCLEX-RN Test 1 for 2026
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NCLEX EXAM PREVIEW NCLEX-RN Practice Questions For 2... NCLEX RN Test 1 for 2026 NCLEX
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Terms in this set (105) Hide definitions
For each finding below, click to specify if the finding is Hemothorax: results from the accumulation of blood loss in the pleural cavity -->
consistent with the disease process of hemothorax or loss of intravascular blood vlolume: tachycardia, hypotension, unilateral
tension pneumothorax. Each finding may support more diminished breath sounds
than one disease process.
Pneumothorax is characterized by air inside the pleural space, which disrupts the
negative pressure that maintains lung expansion, causing the lung to collapse
either partially or completely. Tension pneumothorax develops if air enters but
cannot escape the pleural space --> this trapping compresses the heart and great
vessels and displaces the midline structures (trachea) to the opposite side.
Tension pneumothorax: tachycardia, hypotension, subcutaneous
emphysema/crepitus on palpitation (air gets into the tissue under the skin),
unilateral diminished breath sounds (also tracheal deviation, hyperresonance to
percussion)
Endoctracheal intubation would worsen the existing pneumothorax by delivering
positive pressure ventilation, which would increase intrathoracic pressure ==>
compress the heart and great vessels and lead to cardiac arrest.
The charger nurse is responsible for making room 3. Client who had a bowel resection 1 day ago and client with asthma
assignments multiple clients. Which pari of client exacerbation.
assignments to a shared room is appropriate?
When making room assignments, it is important to remember that a client with an
active or suspected infection should not be paired with a client who has a fresh
surgical wound or is immunocompromised. A client having an asthma
exacerbation does not have an infection and is not at risk for spreading infection
to a client who had a recent bowel resection surgery.
,The clinic nurse is assessing a client who is being treated 2. "I plan to attend my grandchild's graduation next month"
for depression and suicidal ideation. Which client
statement best indicates that the client is not currently at Clients receiving treatment for depression and suicidal ideation must be carefully
risk for suicide? monitored for indications of increasing suicidal intent. During a client interview,
the nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less
likely to attempt death by suicide
The nurse is caring for a client who had an anterior wall 1. Administer potassium supplement
myocardial infarction 2 days ago. The telemetry
technician notifies the nurse at 8:30 AM that the client is In ventricular trigeminy, premature ventricular contractions (PVCs) occur every
in ventricular trigeminy. What is the nurse's priority third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the
intervention? client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias
(eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia,
electrolyte imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L
[3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the
ectopy by administering the prescribed potassium replacement (Option 1). Health
care providers (HCPs) often prescribe electrolyte replacement algorithms to
clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics)
unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L],
anuric, weight <99.2 lb [45 kg]).
The nurse cares for a client with a terminal disease who 3. Explain the client's resuscitation directive to the client's child
created a do not attempt resuscitation (DNAR) directive.
The client stops breathing and loses their pulse. The Clients can create a do not attempt resuscitation (DNAR) directive instructing that
client's adult child states, "Please, do whatever you can to CPR and other life-saving measures be withheld. With an advance directive in
save them!" Which intervention is appropriate? place, the client's wishes should be followed, even if they conflict with the wishes
of loved ones
,The nurse in the cardiac intensive care unit receives 2. Client who underwent coronary artery stent placement via femoral approach 3
report on 4 clients. Which client should the nurse assess hours ago and is reporting severe back pain
first?
A client who undergoes percutaneous coronary intervention (PCI) and
intracoronary stent placement using the femoral approach is at increased risk for
retroperitoneal hemorrhage. Administration of antithrombotic drugs before,
during, and after PCI can exacerbate potentially life-threatening bleeding from
the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma
formation, and diminished distal pulses can be early signs of bleeding into the
retroperitoneal space and require immediate intervention (eg, notify health care
provider, serial complete blood count, CT scan of the abdomen)
The nurse is reviewing the medical history of a client who 4. Peripheral arterial disease
has sustained a right tibia/fibula fracture from a fall. The
nurse identifies which finding as most likely to hinder Bone healing depends on multiple factors, including nutrition, adequate
healing? circulation, and age. A client with peripheral arterial disease has decreased
perfusion to the extremities due to atherosclerotic changes in the arteries.
Without adequate perfusion, the bone is not supplied with the oxygen and
nutrients required for healing
Based on the nursing assessment progress notes, what is WRONG
the correct staging of the client's pressure injury? Click
on the exhibit button for additional information. 2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion,
blister, or shallow crater). The skin blisters or forms an open sore, and the area
around the sore may be red and irritated. (shallow, open ulcer, red-pink wound
with no sloughing and possible intact or ruptured blister)
Stage 1: Intact skin with nonblanchable redness
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving
the dermis or epidermis; the wound bed is red or pink and may be shiny or dry
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon,
muscle, or bone; tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or
eschar (scabbing, dead tissue) may be present; undermining and tunneling may
be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
, A client with type 1 diabetes mellitus has prescriptions for 4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular
NPH insulin and regular insulin. At 0730, the client's blood insulin in the same syringe, drawing up the regular insulin first
glucose level is 322 mg/dL (17.9 mmol/L), and the
breakfast tray has arrived. What action should the nurse Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular)
take? Click the exhibit button for additional information. and rapid-acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should
be drawn into the syringe before intermediate-acting insulin to avoid cross-
contaminating multidose vials (mnemonic - RN: Regular before NPH).
To prepare the mixed dose:
Inject 25 units of air into the NPH insulin vial without inverting the vial or passing
the needle into the solution.
Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no
air bubbles.
Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of
NPH into the syringe will necessitate wasting the entire quantity.
A client is receiving packed RBCs intravenously through a 4. Wait 1 hour after blood transfusion finishes administering amphotericin B
double-lumen peripherally inserted central catheter
(PICC) line. During the transfusion, the nurse receives a Amphotericin B is an antifungal medication used to treat systemic fungal
new prescription to begin intravenous piggyback (IVPB) infections. It is commonly associated with severe adverse effects, including
amphotericin B. What is the nurse's best action? hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the
adverse effects of amphotericin B and the symptoms of a blood transfusion
reaction (eg, chills, fever, hypotension, kidney injury), the nurse's best action is to
complete the blood transfusion and allow one hour of observation before
initiating amphotericin B (Option 4). This enables the nurse to distinguish between
transfusion-related reactions and adverse effects from amphotericin B.
The nurse witnesses the collapse of a child while 1. Initiate chest compressions
outdoors. The child is not breathing and has a pulse of
50/min. The nurse calls emergency services and initiates Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse
rescue breathing. After 2 minutes of rescue breaths, the remains <60/min and there are signs of poor perfusion (skin pallor), the nurse
child is still not breathing and is pale with a pulse of should initiate chest compressions and reassess the pulse every 2 minutes
30/min. What is the nurse's next action?
Findings that require further investigation in a client with Unilateral chest wall expansion (one side of the chest expands more than the
penetrating stab wounds to the neck, chest, and/or other) and diminished breath sounds, which indicate the presence of air (eg, open
abdomen include: pneumothorax) or fluid in the pleural space (eg, hemothorax, pleural effusion)
Vital sign instability (eg, tachycardia, hypotension, tachypnea, hypoxemia) and
signs of poor perfusion (eg, skin pallor), which are concerning for hemorrhage
and respiratory compromise
15 studiers today Leave the first rating
Save Groups
Students also studied
Flashcard sets Study guides
NCLEX EXAM PREVIEW NCLEX-RN Practice Questions For 2... NCLEX RN Test 1 for 2026 NCLEX
110 terms Teacher 34 terms Teacher 312 terms Teacher
kandykat1012 Preview TutorDk Preview TutorDk Preview Tuto
Terms in this set (105) Hide definitions
For each finding below, click to specify if the finding is Hemothorax: results from the accumulation of blood loss in the pleural cavity -->
consistent with the disease process of hemothorax or loss of intravascular blood vlolume: tachycardia, hypotension, unilateral
tension pneumothorax. Each finding may support more diminished breath sounds
than one disease process.
Pneumothorax is characterized by air inside the pleural space, which disrupts the
negative pressure that maintains lung expansion, causing the lung to collapse
either partially or completely. Tension pneumothorax develops if air enters but
cannot escape the pleural space --> this trapping compresses the heart and great
vessels and displaces the midline structures (trachea) to the opposite side.
Tension pneumothorax: tachycardia, hypotension, subcutaneous
emphysema/crepitus on palpitation (air gets into the tissue under the skin),
unilateral diminished breath sounds (also tracheal deviation, hyperresonance to
percussion)
Endoctracheal intubation would worsen the existing pneumothorax by delivering
positive pressure ventilation, which would increase intrathoracic pressure ==>
compress the heart and great vessels and lead to cardiac arrest.
The charger nurse is responsible for making room 3. Client who had a bowel resection 1 day ago and client with asthma
assignments multiple clients. Which pari of client exacerbation.
assignments to a shared room is appropriate?
When making room assignments, it is important to remember that a client with an
active or suspected infection should not be paired with a client who has a fresh
surgical wound or is immunocompromised. A client having an asthma
exacerbation does not have an infection and is not at risk for spreading infection
to a client who had a recent bowel resection surgery.
,The clinic nurse is assessing a client who is being treated 2. "I plan to attend my grandchild's graduation next month"
for depression and suicidal ideation. Which client
statement best indicates that the client is not currently at Clients receiving treatment for depression and suicidal ideation must be carefully
risk for suicide? monitored for indications of increasing suicidal intent. During a client interview,
the nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less
likely to attempt death by suicide
The nurse is caring for a client who had an anterior wall 1. Administer potassium supplement
myocardial infarction 2 days ago. The telemetry
technician notifies the nurse at 8:30 AM that the client is In ventricular trigeminy, premature ventricular contractions (PVCs) occur every
in ventricular trigeminy. What is the nurse's priority third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the
intervention? client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias
(eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia,
electrolyte imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L
[3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the
ectopy by administering the prescribed potassium replacement (Option 1). Health
care providers (HCPs) often prescribe electrolyte replacement algorithms to
clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics)
unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L],
anuric, weight <99.2 lb [45 kg]).
The nurse cares for a client with a terminal disease who 3. Explain the client's resuscitation directive to the client's child
created a do not attempt resuscitation (DNAR) directive.
The client stops breathing and loses their pulse. The Clients can create a do not attempt resuscitation (DNAR) directive instructing that
client's adult child states, "Please, do whatever you can to CPR and other life-saving measures be withheld. With an advance directive in
save them!" Which intervention is appropriate? place, the client's wishes should be followed, even if they conflict with the wishes
of loved ones
,The nurse in the cardiac intensive care unit receives 2. Client who underwent coronary artery stent placement via femoral approach 3
report on 4 clients. Which client should the nurse assess hours ago and is reporting severe back pain
first?
A client who undergoes percutaneous coronary intervention (PCI) and
intracoronary stent placement using the femoral approach is at increased risk for
retroperitoneal hemorrhage. Administration of antithrombotic drugs before,
during, and after PCI can exacerbate potentially life-threatening bleeding from
the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma
formation, and diminished distal pulses can be early signs of bleeding into the
retroperitoneal space and require immediate intervention (eg, notify health care
provider, serial complete blood count, CT scan of the abdomen)
The nurse is reviewing the medical history of a client who 4. Peripheral arterial disease
has sustained a right tibia/fibula fracture from a fall. The
nurse identifies which finding as most likely to hinder Bone healing depends on multiple factors, including nutrition, adequate
healing? circulation, and age. A client with peripheral arterial disease has decreased
perfusion to the extremities due to atherosclerotic changes in the arteries.
Without adequate perfusion, the bone is not supplied with the oxygen and
nutrients required for healing
Based on the nursing assessment progress notes, what is WRONG
the correct staging of the client's pressure injury? Click
on the exhibit button for additional information. 2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion,
blister, or shallow crater). The skin blisters or forms an open sore, and the area
around the sore may be red and irritated. (shallow, open ulcer, red-pink wound
with no sloughing and possible intact or ruptured blister)
Stage 1: Intact skin with nonblanchable redness
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving
the dermis or epidermis; the wound bed is red or pink and may be shiny or dry
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon,
muscle, or bone; tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or
eschar (scabbing, dead tissue) may be present; undermining and tunneling may
be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
, A client with type 1 diabetes mellitus has prescriptions for 4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular
NPH insulin and regular insulin. At 0730, the client's blood insulin in the same syringe, drawing up the regular insulin first
glucose level is 322 mg/dL (17.9 mmol/L), and the
breakfast tray has arrived. What action should the nurse Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular)
take? Click the exhibit button for additional information. and rapid-acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should
be drawn into the syringe before intermediate-acting insulin to avoid cross-
contaminating multidose vials (mnemonic - RN: Regular before NPH).
To prepare the mixed dose:
Inject 25 units of air into the NPH insulin vial without inverting the vial or passing
the needle into the solution.
Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no
air bubbles.
Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of
NPH into the syringe will necessitate wasting the entire quantity.
A client is receiving packed RBCs intravenously through a 4. Wait 1 hour after blood transfusion finishes administering amphotericin B
double-lumen peripherally inserted central catheter
(PICC) line. During the transfusion, the nurse receives a Amphotericin B is an antifungal medication used to treat systemic fungal
new prescription to begin intravenous piggyback (IVPB) infections. It is commonly associated with severe adverse effects, including
amphotericin B. What is the nurse's best action? hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the
adverse effects of amphotericin B and the symptoms of a blood transfusion
reaction (eg, chills, fever, hypotension, kidney injury), the nurse's best action is to
complete the blood transfusion and allow one hour of observation before
initiating amphotericin B (Option 4). This enables the nurse to distinguish between
transfusion-related reactions and adverse effects from amphotericin B.
The nurse witnesses the collapse of a child while 1. Initiate chest compressions
outdoors. The child is not breathing and has a pulse of
50/min. The nurse calls emergency services and initiates Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse
rescue breathing. After 2 minutes of rescue breaths, the remains <60/min and there are signs of poor perfusion (skin pallor), the nurse
child is still not breathing and is pale with a pulse of should initiate chest compressions and reassess the pulse every 2 minutes
30/min. What is the nurse's next action?
Findings that require further investigation in a client with Unilateral chest wall expansion (one side of the chest expands more than the
penetrating stab wounds to the neck, chest, and/or other) and diminished breath sounds, which indicate the presence of air (eg, open
abdomen include: pneumothorax) or fluid in the pleural space (eg, hemothorax, pleural effusion)
Vital sign instability (eg, tachycardia, hypotension, tachypnea, hypoxemia) and
signs of poor perfusion (eg, skin pallor), which are concerning for hemorrhage
and respiratory compromise
