LPN/LVN NCLEX-PN Practice Exam 4 2026 UPDATE |SBON
1. A nurse is caring for a client with a history of congestive heart failure who is
taking Digoxin. Which of the following findings should the nurse report
immediately?
A. Blurred or yellow-tinted vision
B. Heart rate of 78 bpm
C. Increased urine output
D. Blood pressure of 120/80 mmHg
Answer: A
Rationale: Blurred or yellow-tinted vision is a classic sign of Digoxin toxicity and requires
immediate intervention.
2. When administering a regular insulin injection, which action by the student
nurse requires intervention by the clinical instructor?
A. Massaging the site after the injection
B. Rotating the injection site
C. Checking the blood glucose level before administration
D. Checking the expiration date on the vial
Answer: A
Rationale: Massaging the injection site after administering insulin can interfere with the
absorption rate and should be avoided.
,3. A client is diagnosed with tuberculosis (TB). Which type of precautions should
the nurse implement?
A. Airborne precautions
B. Contact precautions
C. Droplet precautions
D. Standard precautions only
Answer: A
Rationale: TB is transmitted via small droplets that remain suspended in the air; therefore,
airborne precautions (including N95 masks) are required.
4. An LPN is assigned to a client who is 2 hours post-operative from an
appendectomy. Which assessment finding is the highest priority?
A. Pain level of 6 out of 10
B. Nausea and vomiting
C. Small amount of serosanguinous drainage on the dressing
D. Oxygen saturation of 88% on room air
Answer: D
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, an oxygen
saturation of 88% indicates respiratory distress and is the most urgent concern.
5. Which of the following is a legal requirement for the LPN regarding informed
consent?
A. Explaining the risks and benefits of the procedure
B. Obtaining the consent after the sedative is administered
C. Deciding if the patient needs the surgery
D. Witnessing the client’s signature on the consent form
Answer: D
Rationale: The nurse’s role is to witness the signature, ensuring the client is competent
and signing voluntarily; the physician is responsible for explaining the procedure.
, 6. A client is prescribed Warfarin. Which food should the nurse instruct the
client to maintain a consistent intake of?
A. Red meat
B. Dairy products
C. Citrus fruits
D. Green leafy vegetables
Answer: D
Rationale: Green leafy vegetables are high in Vitamin K, which is the antagonist to
Warfarin. Sudden changes in intake can affect clotting times.
7. A nurse is assessing a client for signs of hypoglycemia. Which symptom is
expected?
A. Extreme thirst
B. Fruity breath odor
C. Diaphoretic and shaky
D. Abdominal pain
Answer: C
Rationale: Hypoglycemia (low blood sugar) typically causes diaphoresis (sweating),
shakiness, and confusion.
8. What is the first action a nurse should take when a client’s pulse oximeter
reads 82%?
A. Notify the healthcare provider
B. Call for a rapid response team
C. Document the finding
D. Assess the client’s respiratory status and position
Answer: D
Rationale: The nurse should first assess the client to ensure the probe is placed correctly
and check for signs of respiratory distress before calling the doctor.
1. A nurse is caring for a client with a history of congestive heart failure who is
taking Digoxin. Which of the following findings should the nurse report
immediately?
A. Blurred or yellow-tinted vision
B. Heart rate of 78 bpm
C. Increased urine output
D. Blood pressure of 120/80 mmHg
Answer: A
Rationale: Blurred or yellow-tinted vision is a classic sign of Digoxin toxicity and requires
immediate intervention.
2. When administering a regular insulin injection, which action by the student
nurse requires intervention by the clinical instructor?
A. Massaging the site after the injection
B. Rotating the injection site
C. Checking the blood glucose level before administration
D. Checking the expiration date on the vial
Answer: A
Rationale: Massaging the injection site after administering insulin can interfere with the
absorption rate and should be avoided.
,3. A client is diagnosed with tuberculosis (TB). Which type of precautions should
the nurse implement?
A. Airborne precautions
B. Contact precautions
C. Droplet precautions
D. Standard precautions only
Answer: A
Rationale: TB is transmitted via small droplets that remain suspended in the air; therefore,
airborne precautions (including N95 masks) are required.
4. An LPN is assigned to a client who is 2 hours post-operative from an
appendectomy. Which assessment finding is the highest priority?
A. Pain level of 6 out of 10
B. Nausea and vomiting
C. Small amount of serosanguinous drainage on the dressing
D. Oxygen saturation of 88% on room air
Answer: D
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, an oxygen
saturation of 88% indicates respiratory distress and is the most urgent concern.
5. Which of the following is a legal requirement for the LPN regarding informed
consent?
A. Explaining the risks and benefits of the procedure
B. Obtaining the consent after the sedative is administered
C. Deciding if the patient needs the surgery
D. Witnessing the client’s signature on the consent form
Answer: D
Rationale: The nurse’s role is to witness the signature, ensuring the client is competent
and signing voluntarily; the physician is responsible for explaining the procedure.
, 6. A client is prescribed Warfarin. Which food should the nurse instruct the
client to maintain a consistent intake of?
A. Red meat
B. Dairy products
C. Citrus fruits
D. Green leafy vegetables
Answer: D
Rationale: Green leafy vegetables are high in Vitamin K, which is the antagonist to
Warfarin. Sudden changes in intake can affect clotting times.
7. A nurse is assessing a client for signs of hypoglycemia. Which symptom is
expected?
A. Extreme thirst
B. Fruity breath odor
C. Diaphoretic and shaky
D. Abdominal pain
Answer: C
Rationale: Hypoglycemia (low blood sugar) typically causes diaphoresis (sweating),
shakiness, and confusion.
8. What is the first action a nurse should take when a client’s pulse oximeter
reads 82%?
A. Notify the healthcare provider
B. Call for a rapid response team
C. Document the finding
D. Assess the client’s respiratory status and position
Answer: D
Rationale: The nurse should first assess the client to ensure the probe is placed correctly
and check for signs of respiratory distress before calling the doctor.
