NCLEX-PN Exam 2025/2026 (Answered)
100% Verified.
A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the
priority nursing action in the immediate postoperative period?
A. Monitor Vital Signs
B. Assess the proximal pulse at the amputated part
C. Keep a surgical tourniquet t the bedside
D. Administer IV fluids
C. Keep a surgical tourniquet t the bedside
Rationale: Hemorrhage is the most concerning primary immediate complication of amputation.
Therefore, a surgical tourniquet is kept at the bedside in case of acute bleeding.
The practical nurse knows that human papillomavirus infection (HPV) can lead to:
A. Cervical cancer
B. Infertility
C. Pelvic inflammatory disease (PID)
D. Rectal cancer
A. Cervical cancer
Rationale: HPV can lead to cervical cancer due to changes of the cervix from the genital warts. There
is no known connection between HPV and infertility, PID, or rectal cancer.
The nurse is to apply an Ace wrap to the client's right lower leg. Which action should the nurse take
to ensure that the dressing is not too tight:
A. Remove it every hour and reapply
B. Check the pedal pulses
C. Obtain a Doppler study to determine circulation
D. Allow the wrap to remain in place for a minimum of 24 hours
B. Check the pedal pulses
Rationale: To ensure that the Ace wrap is not too tight, the nurse should check the pulse, color, and
temperature of the extremity.
A doctor is preparing to remove a chest tube from a client. Before removing the tube, the nurse
should instruct the client to:
A. Breathe normally
B. Hold breathe and bear down
C. Take a deep breath
D. Cough on demand
B. Hold breathe and bear down
Rationale: The client should be asked to hold breathe and bear down which prevents changes in
pressure until an occlusive dressing is applied.
A client admitted to the floor 3 days ago after a bowel resection suddenly develops chest pain and
shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The
nurse's first action should be to:
,A. Apply 02 at 2L/minute via mask
B. Begin CPR
C. Place the client in high Flower's position
D. Administer a prescribed sedative
C. Place the client in high Flower's position
Rationale: The client during the post-operative period with a widening pulse pressure, SOB, and rales
may have a pulmonary emboli. To facilitate breathing, he should be placed in high Flowler's position.
Oxygen would the be applied.
The nurse is caring for a pt. with a urinary catheter. The nurse should do which of the following to
prevent a urinary tract infection? (select all that apply)
A. Provide perineal care each day and after each bowel movement
B. Change the catheter every day
C. Encourage the pt. to drink fluids
D. Ask the physician to prescribe prophylactic antibiotics
E. Assess the pt. every shift for signs of infection
A. Provide perineal care each day and after each bowel movement
C. Encourage the pt. to drink fluids
E. Assess the pt. every shift for signs of infection
The nurse is caring for a pt. with Raynaud's phenomenon. The nurse should emphasize that the pt.
can reduce symptoms of this disease by:
A. Increase coffee to three cups each day
B. Keeping the house at 68 degrees F.
C. Wearing gloves when handling frozen foods
D. Running cold water over her hands during an episode
C. Wearing gloves when handling frozen foods
Rationale: Raynaud's phenomenon is characterized by vasospasm caused by extreme changes in
temperature. Wearing gloves when handing cold caused by extreme changes in temperature.
Wearing gloves when handing cold foods can help prevent the problem. This phenomenon is
exacerbated by caffeine so the pt. should not increase caffeine intake. A house temperature of 68
degrees F is likely to increase vasospasm. During a vasospastic incident, the pt. can run warm water
over her hands.
A woman in labor has been pushing for one hour and is not making progress. Which of the following
conditions could be hindering the descent of the fetus in the second stage of labor?
A. A full bladder
B. A paracervical block administered during the first stage of labor
C. Mother lying in a side-lying position
D. Fetus in left occiput anterior position
A. A full bladder
During a one-to-one conversation with a nurse, a client says, "I'm worried about my medication.''
The nurse replies, "Tell me more about that." The nurse's response is an example of:
A. Focusing
B. Clarifying
,C. Reflecting
D. Refocusing
A. Focusing
You are caring for a child with cerebral palsy. You notice that the child's movements are very stiff,
and it is very difficult for him to move his joints. What types of cerebral palsy does this child exhibit?
A. Spastic cerebral palsy
B. Ataxic cerebral palsy
C. Athetoid cerebral palsy
D. Coritcate cerebral palsy
A. Spastic cerebral palsy
Rationale: Spastic cerebral palsy causes stiffness and movement difficulties. Athetoid cerebral palsy
leads to involuntary and uncontrolled movements. Ataxic cerebral palsy causes a disturbed sense of
balance and depth perception.
The nurse is caring for a patient with multiple sclerosis. Which of the following symptoms is NOT
indicative of the disease?
A. Muscle weakness
B. Trouble with coordination and balance
C. Thinking and memory problems
D. Hearing Loss
D. Hearing Loss
Rationale: Hearing Loss. Common symptoms of MS include fatigue, weakness, spasticity, balance
problems, bladder and bowel problems, numbness, thinking/memoray problems, vision loss,
tremors and depression.
A patient is diagnosed with acute pancreatitis. Which of the following is the best choice for pain
control?
A. Morphine
B. Ibuprofen
C. Fentanyl
D. Demerol
D. Demerol
Rationale: Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as
well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is
less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
A patient has recently been diagnosed with a peptic ulcer. Upon reviewing lab data, the nurse
notices that the patient's Helicobacter pylori titer is elevated. Which of the following would indicate
the best understanding of the data?
A. Treatment will be to continue to assess and monitor Helicobacter pylori titers
B. Treatment involves educating the patient to avoid solid foods
C. Treatment will consist of Ranitidine and Antibiotics
D. Treatment will involve surgical intervention
C. Treatment will consist of Ranitidine and Antibiotics
Rationale: One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the
gastric and duodenal mucosa which decreases the gastric epithelium's resistance to acid digestion.
, Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce
acid secretion that can lead to an ulcer.
A client with congestive heart failure is being discharged home on a diet restricting sodium to 2000
milligrams per day. The client demonstrates adequate knowledge of the discharge instructions by
avoiding which of the following foods?
A. Plain nuts
B. Canned sardines
C. Spinach
D. Whole milk
B. Canned sardines
Rationale: Canned sardines have the highest sodium content.
A symptom that a client is developing a complication of heart failure is:
A.Increased weight gain
B. Development of ascites
C. Restless and confusion
D. Increased liver enzymes
D. Increased liver enzymes
Rationale: All of the symptoms mentioned are found in heart failure; however increased liver
enzymes indicate congestion in the heart has reached the liver.
A patient presents with complaints of generally not feeling well for 2 weeks, fatigue and occasional
dizziness. The patient is placed on a cardiac monitor which shows a regular ventricular rate of 33 and
more P waves than QRS complexes that do not seem to be associated. The patient is most likely
experiencing:
A. 1st degree heart block
B. Sinus bradycardia
C. 3rd degree heart block
D. Junctional rhythm
C. 3rd degree heart block
Rationale: In 3rd degree heart block there are more P waves than QRS complexes and there is no
association between the P waves (atrial contraction) and QRS complexes (ventricular contraction).
Which situation necessitates the use of restraints on a client?
A. Insufficient staffing on the unit
B. The client is confused and combative
C. Family request to make sure client is safe
D. Medical evaluation and written provider orders
D. Medical evaluation and written provider orders
Rationale: A medical evaluation and written healthcare provider orders that are timed and dated as
per agency policy is required for the use of restraints.
A client experiences an episode of pulmonary edema because the nurse forgot to administer the
morning dose of furosemide (Lasix). Which legal element can the nurse be charged with?
A. Assault
B. Slander
100% Verified.
A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the
priority nursing action in the immediate postoperative period?
A. Monitor Vital Signs
B. Assess the proximal pulse at the amputated part
C. Keep a surgical tourniquet t the bedside
D. Administer IV fluids
C. Keep a surgical tourniquet t the bedside
Rationale: Hemorrhage is the most concerning primary immediate complication of amputation.
Therefore, a surgical tourniquet is kept at the bedside in case of acute bleeding.
The practical nurse knows that human papillomavirus infection (HPV) can lead to:
A. Cervical cancer
B. Infertility
C. Pelvic inflammatory disease (PID)
D. Rectal cancer
A. Cervical cancer
Rationale: HPV can lead to cervical cancer due to changes of the cervix from the genital warts. There
is no known connection between HPV and infertility, PID, or rectal cancer.
The nurse is to apply an Ace wrap to the client's right lower leg. Which action should the nurse take
to ensure that the dressing is not too tight:
A. Remove it every hour and reapply
B. Check the pedal pulses
C. Obtain a Doppler study to determine circulation
D. Allow the wrap to remain in place for a minimum of 24 hours
B. Check the pedal pulses
Rationale: To ensure that the Ace wrap is not too tight, the nurse should check the pulse, color, and
temperature of the extremity.
A doctor is preparing to remove a chest tube from a client. Before removing the tube, the nurse
should instruct the client to:
A. Breathe normally
B. Hold breathe and bear down
C. Take a deep breath
D. Cough on demand
B. Hold breathe and bear down
Rationale: The client should be asked to hold breathe and bear down which prevents changes in
pressure until an occlusive dressing is applied.
A client admitted to the floor 3 days ago after a bowel resection suddenly develops chest pain and
shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The
nurse's first action should be to:
,A. Apply 02 at 2L/minute via mask
B. Begin CPR
C. Place the client in high Flower's position
D. Administer a prescribed sedative
C. Place the client in high Flower's position
Rationale: The client during the post-operative period with a widening pulse pressure, SOB, and rales
may have a pulmonary emboli. To facilitate breathing, he should be placed in high Flowler's position.
Oxygen would the be applied.
The nurse is caring for a pt. with a urinary catheter. The nurse should do which of the following to
prevent a urinary tract infection? (select all that apply)
A. Provide perineal care each day and after each bowel movement
B. Change the catheter every day
C. Encourage the pt. to drink fluids
D. Ask the physician to prescribe prophylactic antibiotics
E. Assess the pt. every shift for signs of infection
A. Provide perineal care each day and after each bowel movement
C. Encourage the pt. to drink fluids
E. Assess the pt. every shift for signs of infection
The nurse is caring for a pt. with Raynaud's phenomenon. The nurse should emphasize that the pt.
can reduce symptoms of this disease by:
A. Increase coffee to three cups each day
B. Keeping the house at 68 degrees F.
C. Wearing gloves when handling frozen foods
D. Running cold water over her hands during an episode
C. Wearing gloves when handling frozen foods
Rationale: Raynaud's phenomenon is characterized by vasospasm caused by extreme changes in
temperature. Wearing gloves when handing cold caused by extreme changes in temperature.
Wearing gloves when handing cold foods can help prevent the problem. This phenomenon is
exacerbated by caffeine so the pt. should not increase caffeine intake. A house temperature of 68
degrees F is likely to increase vasospasm. During a vasospastic incident, the pt. can run warm water
over her hands.
A woman in labor has been pushing for one hour and is not making progress. Which of the following
conditions could be hindering the descent of the fetus in the second stage of labor?
A. A full bladder
B. A paracervical block administered during the first stage of labor
C. Mother lying in a side-lying position
D. Fetus in left occiput anterior position
A. A full bladder
During a one-to-one conversation with a nurse, a client says, "I'm worried about my medication.''
The nurse replies, "Tell me more about that." The nurse's response is an example of:
A. Focusing
B. Clarifying
,C. Reflecting
D. Refocusing
A. Focusing
You are caring for a child with cerebral palsy. You notice that the child's movements are very stiff,
and it is very difficult for him to move his joints. What types of cerebral palsy does this child exhibit?
A. Spastic cerebral palsy
B. Ataxic cerebral palsy
C. Athetoid cerebral palsy
D. Coritcate cerebral palsy
A. Spastic cerebral palsy
Rationale: Spastic cerebral palsy causes stiffness and movement difficulties. Athetoid cerebral palsy
leads to involuntary and uncontrolled movements. Ataxic cerebral palsy causes a disturbed sense of
balance and depth perception.
The nurse is caring for a patient with multiple sclerosis. Which of the following symptoms is NOT
indicative of the disease?
A. Muscle weakness
B. Trouble with coordination and balance
C. Thinking and memory problems
D. Hearing Loss
D. Hearing Loss
Rationale: Hearing Loss. Common symptoms of MS include fatigue, weakness, spasticity, balance
problems, bladder and bowel problems, numbness, thinking/memoray problems, vision loss,
tremors and depression.
A patient is diagnosed with acute pancreatitis. Which of the following is the best choice for pain
control?
A. Morphine
B. Ibuprofen
C. Fentanyl
D. Demerol
D. Demerol
Rationale: Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as
well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is
less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
A patient has recently been diagnosed with a peptic ulcer. Upon reviewing lab data, the nurse
notices that the patient's Helicobacter pylori titer is elevated. Which of the following would indicate
the best understanding of the data?
A. Treatment will be to continue to assess and monitor Helicobacter pylori titers
B. Treatment involves educating the patient to avoid solid foods
C. Treatment will consist of Ranitidine and Antibiotics
D. Treatment will involve surgical intervention
C. Treatment will consist of Ranitidine and Antibiotics
Rationale: One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the
gastric and duodenal mucosa which decreases the gastric epithelium's resistance to acid digestion.
, Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce
acid secretion that can lead to an ulcer.
A client with congestive heart failure is being discharged home on a diet restricting sodium to 2000
milligrams per day. The client demonstrates adequate knowledge of the discharge instructions by
avoiding which of the following foods?
A. Plain nuts
B. Canned sardines
C. Spinach
D. Whole milk
B. Canned sardines
Rationale: Canned sardines have the highest sodium content.
A symptom that a client is developing a complication of heart failure is:
A.Increased weight gain
B. Development of ascites
C. Restless and confusion
D. Increased liver enzymes
D. Increased liver enzymes
Rationale: All of the symptoms mentioned are found in heart failure; however increased liver
enzymes indicate congestion in the heart has reached the liver.
A patient presents with complaints of generally not feeling well for 2 weeks, fatigue and occasional
dizziness. The patient is placed on a cardiac monitor which shows a regular ventricular rate of 33 and
more P waves than QRS complexes that do not seem to be associated. The patient is most likely
experiencing:
A. 1st degree heart block
B. Sinus bradycardia
C. 3rd degree heart block
D. Junctional rhythm
C. 3rd degree heart block
Rationale: In 3rd degree heart block there are more P waves than QRS complexes and there is no
association between the P waves (atrial contraction) and QRS complexes (ventricular contraction).
Which situation necessitates the use of restraints on a client?
A. Insufficient staffing on the unit
B. The client is confused and combative
C. Family request to make sure client is safe
D. Medical evaluation and written provider orders
D. Medical evaluation and written provider orders
Rationale: A medical evaluation and written healthcare provider orders that are timed and dated as
per agency policy is required for the use of restraints.
A client experiences an episode of pulmonary edema because the nurse forgot to administer the
morning dose of furosemide (Lasix). Which legal element can the nurse be charged with?
A. Assault
B. Slander
