NCSBN NCLEX QUESTIONS AND
ANSWERS UPDATED 2026, Exams of
Nursing questions and answers already
graded A+
The client is receiving a thrombolytic agent to open a clot-occluded coronary artery
following a myocardial infarction. Which finding would be the greatest concern and
should be immediately reported to the registered nurse?
1Hematemesis -
2Pink-tinged saliva
3Serosanguinous drainage from the IV site
4Slight rust-colored urine - --ANS---1Hematemesis -
The nurse is caring for a postoperative client following a closed reduction of distal tibia
and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after
surgery, the client suddenly becomes confused, short of breath and spikes a
temperature of 103 F (39.4 C). What should be the first action by the nurse?
1Check the distal circulation of the casted extremity
2Obtain the pulse oximetry reading
3Measure the client's blood pressure in the supine and Fowler's positions
4Check the orientation to time, place and person - --ANS---2
The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the
priority action by the nurse to accurately assess correct placement of the G-tube?
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shift - --ANS---1Listen for
active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate -
3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds
in all four quadrants
2Measure the pH of stomach content aspirate -
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shifto the G-tube
4Measure the length of tubing from the insertion site each shift
,The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding
suggests a complication of this condition?
1Pronounced wheezes
2Pain on deep inspiration
3Sudden back pain
4Sudden dyspnea - --ANS---4
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA).
What should the nurse understand about the purpose of this procedure?
1The surgical repair of a diseased coronary artery
2An noninvasive radiographic examination of the heart
3A process to compress arterial plaque to improve blood flow
4The placement of an automatic internal cardiac defibrillator - --ANS---3
A 2 day-old infant born with spina bifida and meningomyocele is recovering after an
initial surgery. As the nurse accompanies the grandparents for their first visit since the
child's birth, which of these responses might the nurse expect from the grandparents?
1Anger
2Disbelief
3Depression
4Frustration - --ANS---2
The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring
system (eICU.) What is one of the best reasons for having access to an eICU?
1An ICU nurse and intensivist remotely monitor ICU clients around the clock
2An ICU nurse is on-call to answer questions when needed
3Clients can ask the intensivist for a second opinion
4Less staff is needed on site when a remote eICU is available - --ANS---1
A child has severe burns to the lower extremities. A diet high in protein and
carbohydrates is recommended. The nurse should care for this client with the
knowledge that the most important reason for such a diet is to achieve which result?
1Provide a well-balanced nutritional intake
2Promote healing and strengthen the immune system
3Spare protein catabolism to meet metabolic and healing needs
4 stimulate increased peristalsis and nutrient absorption - --ANS---3
A nurse is reinforcing information about the administration of an albuterol inhaler to an
adult diagnosed with asthma. What should be the priority comment made by the nurse?
1"Use this medication at bedtime to promote rest."
2"Notify the health care provider if your canister lasts only two weeks."
3"Inhale this medication after other asthma sprays."
4"Discontinue the inhaler if you are dizzy." - --ANS---2
An 80 year-old client is hospitalized for a chronic condition. The client informs family
members that a living will has been prepared and the client wants no life-prolonging
,measures performed. The client's condition deteriorates and the client becomes
unresponsive. Which of the following nursing actions is most appropriate?
1Notify the attending physician
2Consult the charge nurse and prepare to transfer the client to an intensive care unit
3Call the rapid response team
4Contact the family member indicated in the admission forms - --ANS---1
The nurse is caring for a client who has just been admitted to the inpatient mental health
unit with severe depression. Which concern should be a priority of care?
1Safety
2Elimination
3Rest
4Nutrition - --ANS---1
A nurse is discussing with a client the precautions with warfarin. The nurse should tell
the client to avoid foods with excessive amounts of what substance?
1Iron
2Calcium
3Vitamin E
4Vitamin K - --ANS---4
The nurse has established a therapeutic relationship with a client. Which observation
would indicate that the nurse-client relationship has passed from the orienting phase to
the working phase?
1The client revitalizes a relationship with the family to help in coping with a child's death
2The client recognizes feelings and expresses them appropriately
3The client expresses a desire to be mothered and pampered
4The client recognizes regression as a part of a defense mechanism - --ANS---2
During the working phase, problems are identified and the client is able to focus on
unpleasant feelings and express them appropriately.
During the working phase, problems are identified and the client is able to focus on
unpleasant feelings and express them appropriately. - --ANS---An advance health care
directive is also known as a living will. It is a legal document in which a person specifies
his or her wishes concerning medical treatments at the end-of-life, when s/he is unable
to make those decisions. Advance care planning involves sharing personal values and
wishes with loved ones and selecting someone, (called a medical power of attorney or
health care proxy) who will eventually make medical decisions on the client's behalf
A nurse is talking to a group of parents about how to reduce risks in the home. What is
the most important factor for the nurse to consider during the discussion?
1Proximity to emergency services
2Number of children in the home
3Knowledge level of the parents
4Age of children in the home - --ANS---4
, When reviewing the medication lithium with a client, the client asks, "How long will it
take before I can feel the effects of the medication?" Which response by the nurse is the
best?
1"About two weeks"
2"One month"
3"Immediately"
4"Several days" - --ANS---1
A client has completed a renal biopsy. Which nursing intervention is appropriate after a
renal biopsy?
1Ambulate the client within four hours after procedure
2Change the dressing when it becomes saturated
3Monitor vital signs using post-op protocols
4Maintain client on NPO status for 24 hours - --ANS---3
The nurse is caring for a client who is one-day postoperative with a T-tube following a
cholecystectomy. What color would the nurse expect the drainage from the client's T-
tube to be?
1Dark brown
2Green
3Yellowish-brown
4Orange - --ANS---3
A newly admitted client reports taking phenytoin for several months. Which of the
following assessments should the nurse be sure to include in the admission report?
(Select all that apply.) - --ANS---Serious adverse outcomes of antiseizure medications
such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred
vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or
increased urination are additional serious side effects.
The nurse is giving a morning bath to a client who has a colostomy. While giving the
bath, the nurse should reinforce that the collection pouch should be emptied at what
time?
1Prior to going to sleep at night
2After each fecal elimination
3At the same time each day
4When it is one-third to one-half full - --ANS---4
A client is scheduled to have blood drawn for serum cholesterol and triglycerides
tomorrow morning. What information should the nurse reinforce to the client about the
test?
1"Be sure to eat a fat-free diet until the test, and drink lots of water."
2"Stay at the laboratory so that two blood samples can be drawn an hour apart."
3"Do not eat or drink anything but water for 12 hours before the blood test."
4"Have the blood drawn within two hours of eating breakfast." - --ANS---3
ANSWERS UPDATED 2026, Exams of
Nursing questions and answers already
graded A+
The client is receiving a thrombolytic agent to open a clot-occluded coronary artery
following a myocardial infarction. Which finding would be the greatest concern and
should be immediately reported to the registered nurse?
1Hematemesis -
2Pink-tinged saliva
3Serosanguinous drainage from the IV site
4Slight rust-colored urine - --ANS---1Hematemesis -
The nurse is caring for a postoperative client following a closed reduction of distal tibia
and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after
surgery, the client suddenly becomes confused, short of breath and spikes a
temperature of 103 F (39.4 C). What should be the first action by the nurse?
1Check the distal circulation of the casted extremity
2Obtain the pulse oximetry reading
3Measure the client's blood pressure in the supine and Fowler's positions
4Check the orientation to time, place and person - --ANS---2
The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the
priority action by the nurse to accurately assess correct placement of the G-tube?
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shift - --ANS---1Listen for
active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate -
3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds
in all four quadrants
2Measure the pH of stomach content aspirate -
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shifto the G-tube
4Measure the length of tubing from the insertion site each shift
,The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding
suggests a complication of this condition?
1Pronounced wheezes
2Pain on deep inspiration
3Sudden back pain
4Sudden dyspnea - --ANS---4
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA).
What should the nurse understand about the purpose of this procedure?
1The surgical repair of a diseased coronary artery
2An noninvasive radiographic examination of the heart
3A process to compress arterial plaque to improve blood flow
4The placement of an automatic internal cardiac defibrillator - --ANS---3
A 2 day-old infant born with spina bifida and meningomyocele is recovering after an
initial surgery. As the nurse accompanies the grandparents for their first visit since the
child's birth, which of these responses might the nurse expect from the grandparents?
1Anger
2Disbelief
3Depression
4Frustration - --ANS---2
The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring
system (eICU.) What is one of the best reasons for having access to an eICU?
1An ICU nurse and intensivist remotely monitor ICU clients around the clock
2An ICU nurse is on-call to answer questions when needed
3Clients can ask the intensivist for a second opinion
4Less staff is needed on site when a remote eICU is available - --ANS---1
A child has severe burns to the lower extremities. A diet high in protein and
carbohydrates is recommended. The nurse should care for this client with the
knowledge that the most important reason for such a diet is to achieve which result?
1Provide a well-balanced nutritional intake
2Promote healing and strengthen the immune system
3Spare protein catabolism to meet metabolic and healing needs
4 stimulate increased peristalsis and nutrient absorption - --ANS---3
A nurse is reinforcing information about the administration of an albuterol inhaler to an
adult diagnosed with asthma. What should be the priority comment made by the nurse?
1"Use this medication at bedtime to promote rest."
2"Notify the health care provider if your canister lasts only two weeks."
3"Inhale this medication after other asthma sprays."
4"Discontinue the inhaler if you are dizzy." - --ANS---2
An 80 year-old client is hospitalized for a chronic condition. The client informs family
members that a living will has been prepared and the client wants no life-prolonging
,measures performed. The client's condition deteriorates and the client becomes
unresponsive. Which of the following nursing actions is most appropriate?
1Notify the attending physician
2Consult the charge nurse and prepare to transfer the client to an intensive care unit
3Call the rapid response team
4Contact the family member indicated in the admission forms - --ANS---1
The nurse is caring for a client who has just been admitted to the inpatient mental health
unit with severe depression. Which concern should be a priority of care?
1Safety
2Elimination
3Rest
4Nutrition - --ANS---1
A nurse is discussing with a client the precautions with warfarin. The nurse should tell
the client to avoid foods with excessive amounts of what substance?
1Iron
2Calcium
3Vitamin E
4Vitamin K - --ANS---4
The nurse has established a therapeutic relationship with a client. Which observation
would indicate that the nurse-client relationship has passed from the orienting phase to
the working phase?
1The client revitalizes a relationship with the family to help in coping with a child's death
2The client recognizes feelings and expresses them appropriately
3The client expresses a desire to be mothered and pampered
4The client recognizes regression as a part of a defense mechanism - --ANS---2
During the working phase, problems are identified and the client is able to focus on
unpleasant feelings and express them appropriately.
During the working phase, problems are identified and the client is able to focus on
unpleasant feelings and express them appropriately. - --ANS---An advance health care
directive is also known as a living will. It is a legal document in which a person specifies
his or her wishes concerning medical treatments at the end-of-life, when s/he is unable
to make those decisions. Advance care planning involves sharing personal values and
wishes with loved ones and selecting someone, (called a medical power of attorney or
health care proxy) who will eventually make medical decisions on the client's behalf
A nurse is talking to a group of parents about how to reduce risks in the home. What is
the most important factor for the nurse to consider during the discussion?
1Proximity to emergency services
2Number of children in the home
3Knowledge level of the parents
4Age of children in the home - --ANS---4
, When reviewing the medication lithium with a client, the client asks, "How long will it
take before I can feel the effects of the medication?" Which response by the nurse is the
best?
1"About two weeks"
2"One month"
3"Immediately"
4"Several days" - --ANS---1
A client has completed a renal biopsy. Which nursing intervention is appropriate after a
renal biopsy?
1Ambulate the client within four hours after procedure
2Change the dressing when it becomes saturated
3Monitor vital signs using post-op protocols
4Maintain client on NPO status for 24 hours - --ANS---3
The nurse is caring for a client who is one-day postoperative with a T-tube following a
cholecystectomy. What color would the nurse expect the drainage from the client's T-
tube to be?
1Dark brown
2Green
3Yellowish-brown
4Orange - --ANS---3
A newly admitted client reports taking phenytoin for several months. Which of the
following assessments should the nurse be sure to include in the admission report?
(Select all that apply.) - --ANS---Serious adverse outcomes of antiseizure medications
such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred
vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or
increased urination are additional serious side effects.
The nurse is giving a morning bath to a client who has a colostomy. While giving the
bath, the nurse should reinforce that the collection pouch should be emptied at what
time?
1Prior to going to sleep at night
2After each fecal elimination
3At the same time each day
4When it is one-third to one-half full - --ANS---4
A client is scheduled to have blood drawn for serum cholesterol and triglycerides
tomorrow morning. What information should the nurse reinforce to the client about the
test?
1"Be sure to eat a fat-free diet until the test, and drink lots of water."
2"Stay at the laboratory so that two blood samples can be drawn an hour apart."
3"Do not eat or drink anything but water for 12 hours before the blood test."
4"Have the blood drawn within two hours of eating breakfast." - --ANS---3
