LPN/LVN Medical-Surgical Nursing Disorders NCLEX-PN 2026/2027
Prep UPDATE|SBON
1. A nurse is caring for a client with left-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Crackles in the lungs
B. Jugular venous distention
C. Peripheral edema
D. Abdominal distention
Answer: A
Rationale: Left-sided heart failure causes blood to back up into the pulmonary system,
leading to pulmonary congestion and crackles. The other options are signs of right-sided
heart failure.
2. Which laboratory value is the most important for the nurse to monitor for a
client receiving heparin therapy?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. International Normalized Ratio (INR)
D. Platelet count
Answer: B
Rationale: The aPTT is used to monitor the effectiveness of heparin therapy. PT and INR
are used for warfarin therapy.
,3. A client with Type 1 Diabetes Mellitus is found unconscious and diaphoretic.
What should be the nurse’s first action?
A. Administer 15g of oral carbohydrates
B. Administer glucagon intramuscularly
C. Check the blood glucose level
D. Notify the healthcare provider
Answer: B
Rationale: For an unconscious client with suspected hypoglycemia, an intramuscular
injection of glucagon or IV dextrose is necessary as they cannot safely swallow oral glucose.
4. A nurse is providing discharge teaching for a client with a new prescription for
warfarin. Which food should the nurse instruct the client to eat in consistent
amounts?
A. Bananas
B. Whole grain bread
C. Red meat
D. Spinach
Answer: D
Rationale: Spinach is high in Vitamin K, which is the antidote for warfarin. Sudden changes
in Vitamin K intake can affect the medication’s efficacy; therefore, intake must be
consistent.
5. Which assessment finding in a client with a leg fracture and a cast requires
immediate notification of the healthcare provider?
A. Mild itching under the cast
B. Pain relieved by ibuprofen
C. Small amount of serosanguinous drainage
D. Toes that are cool to the touch and pale
Answer: D
, Rationale: Cool, pale toes can indicate neurovascular compromise or compartment
syndrome, which is a medical emergency.
6. What is the primary goal of care for a client during the acute phase of an
ischemic stroke?
A. Starting physical therapy
B. Preventing skin breakdown
C. Teaching lifestyle modifications
D. Maintaining a patent airway
Answer: D
Rationale: In any acute emergency, maintaining the ABCs (Airway, Breathing, Circulation)
is the top priority.
7. A nurse is caring for a client with chronic obstructive pulmonary disease
(COPD). Which oxygen delivery rate is typically appropriate for this client?
A. 10-15 L/min via non-rebreather mask
B. No oxygen should be given
C. 6-8 L/min via simple face mask
D. 1-2 L/min via nasal cannula
Answer: D
Rationale: Low-flow oxygen is preferred for COPD clients because high levels of oxygen
can suppress their hypoxic drive to breathe.
8. A client is diagnosed with hyperthyroidism. Which vital sign change is most
likely associated with this condition?
A. Bradycardia
B. Tachycardia
C. Bradypnea
D. Hypotension
Answer: B
Prep UPDATE|SBON
1. A nurse is caring for a client with left-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Crackles in the lungs
B. Jugular venous distention
C. Peripheral edema
D. Abdominal distention
Answer: A
Rationale: Left-sided heart failure causes blood to back up into the pulmonary system,
leading to pulmonary congestion and crackles. The other options are signs of right-sided
heart failure.
2. Which laboratory value is the most important for the nurse to monitor for a
client receiving heparin therapy?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. International Normalized Ratio (INR)
D. Platelet count
Answer: B
Rationale: The aPTT is used to monitor the effectiveness of heparin therapy. PT and INR
are used for warfarin therapy.
,3. A client with Type 1 Diabetes Mellitus is found unconscious and diaphoretic.
What should be the nurse’s first action?
A. Administer 15g of oral carbohydrates
B. Administer glucagon intramuscularly
C. Check the blood glucose level
D. Notify the healthcare provider
Answer: B
Rationale: For an unconscious client with suspected hypoglycemia, an intramuscular
injection of glucagon or IV dextrose is necessary as they cannot safely swallow oral glucose.
4. A nurse is providing discharge teaching for a client with a new prescription for
warfarin. Which food should the nurse instruct the client to eat in consistent
amounts?
A. Bananas
B. Whole grain bread
C. Red meat
D. Spinach
Answer: D
Rationale: Spinach is high in Vitamin K, which is the antidote for warfarin. Sudden changes
in Vitamin K intake can affect the medication’s efficacy; therefore, intake must be
consistent.
5. Which assessment finding in a client with a leg fracture and a cast requires
immediate notification of the healthcare provider?
A. Mild itching under the cast
B. Pain relieved by ibuprofen
C. Small amount of serosanguinous drainage
D. Toes that are cool to the touch and pale
Answer: D
, Rationale: Cool, pale toes can indicate neurovascular compromise or compartment
syndrome, which is a medical emergency.
6. What is the primary goal of care for a client during the acute phase of an
ischemic stroke?
A. Starting physical therapy
B. Preventing skin breakdown
C. Teaching lifestyle modifications
D. Maintaining a patent airway
Answer: D
Rationale: In any acute emergency, maintaining the ABCs (Airway, Breathing, Circulation)
is the top priority.
7. A nurse is caring for a client with chronic obstructive pulmonary disease
(COPD). Which oxygen delivery rate is typically appropriate for this client?
A. 10-15 L/min via non-rebreather mask
B. No oxygen should be given
C. 6-8 L/min via simple face mask
D. 1-2 L/min via nasal cannula
Answer: D
Rationale: Low-flow oxygen is preferred for COPD clients because high levels of oxygen
can suppress their hypoxic drive to breathe.
8. A client is diagnosed with hyperthyroidism. Which vital sign change is most
likely associated with this condition?
A. Bradycardia
B. Tachycardia
C. Bradypnea
D. Hypotension
Answer: B
