NCLEX RN Comprehensive Practice
Exam 005 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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1. A nurse is caring for a client who has just returned from the post anesthesia
care unit following a laparoscopic cholecystectomy. The client reports severe right
shoulder pain. Which of the following actions should the nurse take first?
A. Administer the prescribed opioid analgesic.
B. Apply a heating pad to the client's right shoulder.
C. Place the client in a supine position with the head of the bed flat.
D. Auscultate the client's lung sounds.
Answer: D
Rationale: Right shoulder pain after laparoscopic surgery is often referred pain
from diaphragmatic irritation caused by residual carbon dioxide gas used to
insufflate the abdomen. However, the nurse must first rule out more serious
causes, such as a pneumothorax or atelectasis, which can present with shoulder or
chest pain. Auscultating lung sounds is the priority action to assess for diminished
breath sounds or unexpected findings that could indicate a respiratory
complication. While administering analgesia and repositioning are appropriate
interventions after the assessment, they should not precede the evaluation of the
client's respiratory status. A heating pad is not recommended without a clear
diagnosis and could mask an underlying issue.
2. A client with a history of heart failure is admitted with acute pulmonary edema.
The provider prescribes furosemide 40 mg intravenously. Which assessment
finding indicates that the medication has achieved its intended therapeutic effect?
,A. Decreased urinary output.
B. Increased heart rate.
C. Decreased crackles in the lung bases.
D. Increased blood pressure.
Answer: C
Rationale: Furosemide is a loop diuretic that promotes the excretion of sodium
and water, thereby reducing preload and fluid volume overload. In a client with
pulmonary edema, the therapeutic goal is to reduce the amount of fluid in the
lungs, which is evidenced by a decrease in adventitious breath sounds such as
crackles or rales. Decreased urinary output would indicate a lack of response to
the diuretic or worsening renal function, not a therapeutic effect. Increased heart
rate or blood pressure would suggest hemodynamic instability or a stress
response, not a desired outcome of diuresis.
3. A nurse is preparing to administer a blood transfusion to a client. Which of the
following actions is most important to prevent a transfusion reaction?
A. Verify the client's identity using two identifiers.
B. Check the client's baseline vital signs.
C. Prime the blood tubing with normal saline.
D. Monitor the client for the first 15 minutes.
Answer: A
Rationale: The most critical step in preventing a transfusion reaction is ensuring
that the blood product is administered to the correct client. This is accomplished
by verifying the client's identity using at least two unique identifiers (e.g., name,
date of birth, medical record number) against the blood component label and the
transfusion order. While checking vital signs, priming with normal saline, and
monitoring are all important steps in the transfusion process, they are secondary
to the verification of identity, which directly prevents the most common cause of
ABO incompatibility reactions.
4. A primigravida at 39 weeks gestation presents to the labor and delivery unit
with contractions every 3 to 4 minutes. A vaginal examination reveals that her
,cervix is 4 cm dilated, 90% effaced, and the fetal presenting part is at a station of
1. Which of the following phases of labor is the client experiencing?
A. Latent phase of the first stage.
B. Active phase of the first stage.
C. Transition phase of the first stage.
D. Second stage of labor.
Answer: B
Rationale: The first stage of labor is divided into three phases. The latent phase is
from 0 to approximately 4 cm dilation. The active phase, characterized by more
rapid cervical dilation, is generally from 4 cm to 7 cm dilation. The transition phase
is from 8 cm to 10 cm dilation. Since the client is 4 cm dilated and having regular
contractions, she is entering or is in the active phase. The second stage of labor
begins when the cervix is fully dilated (10 cm) and ends with the birth of the infant.
Station 1 indicates the presenting part is 1 cm below the ischial spines, which is
consistent with active labor.
5. A school nurse is teaching a group of adolescents about the prevention of
sexually transmitted infections. Which of the following statements by a student
indicates a need for further teaching?
A. "I should use a condom every time I have sex."
B. "I can get an infection even if I only have sex once."
C. "If I have no symptoms, I cannot pass an infection to someone else."
D. "I should get tested for STIs if I have a new partner."
Answer: C
Rationale: Many sexually transmitted infections are asymptomatic, meaning an
individual can be infected and contagious without exhibiting any signs or
symptoms. Chlamydia, gonorrhea, and human papillomavirus are examples of
infections that often present without symptoms. The statement "If I have no
symptoms, I cannot pass an infection to someone else" reflects a dangerous
misconception and indicates a need for further teaching. The other statements are
accurate and indicate an understanding of STI prevention and transmission.
, 6. A client is prescribed a low sodium diet for the management of hypertension.
Which of the following food choices should the nurse encourage the client to
avoid?
A. Fresh apples.
B. Baked chicken breast.
C. Canned tomato soup.
D. Unsalted almonds.
Answer: C
Rationale: Canned tomato soup is a processed food that is typically high in sodium
to enhance flavor and act as a preservative. A low sodium diet restricts sodium
intake to generally less than 2,300 mg per day, and often much lower. Fresh fruits,
unsalted nuts, and fresh, unseasoned meats are naturally low in sodium and are
appropriate choices for a client following a low sodium diet.
7. A nurse is assessing a client who has a chest tube attached to a water seal
drainage system. The nurse notes that the water in the water seal chamber is
gently bubbling. Which of the following actions should the nurse take?
A. Increase the suction to the prescribed level.
B. Notify the healthcare provider immediately.
C. Clamp the chest tube close to the insertion site.
D. Document the finding as an expected observation.
Answer: D
Rationale: In a wet suction water seal chest drainage system, intermittent
bubbling in the water seal chamber is an expected and normal finding. This
bubbling indicates that air is being evacuated from the pleural space and is exiting
through the water seal. Continuous, vigorous bubbling would indicate a leak in the
system. The nurse should document this normal finding and continue to monitor
the system. Clamping the tube should never be done without a specific order as it
could lead to a tension pneumothorax. Increasing suction or notifying the provider
is not indicated for this expected finding.
Exam 005 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. A nurse is caring for a client who has just returned from the post anesthesia
care unit following a laparoscopic cholecystectomy. The client reports severe right
shoulder pain. Which of the following actions should the nurse take first?
A. Administer the prescribed opioid analgesic.
B. Apply a heating pad to the client's right shoulder.
C. Place the client in a supine position with the head of the bed flat.
D. Auscultate the client's lung sounds.
Answer: D
Rationale: Right shoulder pain after laparoscopic surgery is often referred pain
from diaphragmatic irritation caused by residual carbon dioxide gas used to
insufflate the abdomen. However, the nurse must first rule out more serious
causes, such as a pneumothorax or atelectasis, which can present with shoulder or
chest pain. Auscultating lung sounds is the priority action to assess for diminished
breath sounds or unexpected findings that could indicate a respiratory
complication. While administering analgesia and repositioning are appropriate
interventions after the assessment, they should not precede the evaluation of the
client's respiratory status. A heating pad is not recommended without a clear
diagnosis and could mask an underlying issue.
2. A client with a history of heart failure is admitted with acute pulmonary edema.
The provider prescribes furosemide 40 mg intravenously. Which assessment
finding indicates that the medication has achieved its intended therapeutic effect?
,A. Decreased urinary output.
B. Increased heart rate.
C. Decreased crackles in the lung bases.
D. Increased blood pressure.
Answer: C
Rationale: Furosemide is a loop diuretic that promotes the excretion of sodium
and water, thereby reducing preload and fluid volume overload. In a client with
pulmonary edema, the therapeutic goal is to reduce the amount of fluid in the
lungs, which is evidenced by a decrease in adventitious breath sounds such as
crackles or rales. Decreased urinary output would indicate a lack of response to
the diuretic or worsening renal function, not a therapeutic effect. Increased heart
rate or blood pressure would suggest hemodynamic instability or a stress
response, not a desired outcome of diuresis.
3. A nurse is preparing to administer a blood transfusion to a client. Which of the
following actions is most important to prevent a transfusion reaction?
A. Verify the client's identity using two identifiers.
B. Check the client's baseline vital signs.
C. Prime the blood tubing with normal saline.
D. Monitor the client for the first 15 minutes.
Answer: A
Rationale: The most critical step in preventing a transfusion reaction is ensuring
that the blood product is administered to the correct client. This is accomplished
by verifying the client's identity using at least two unique identifiers (e.g., name,
date of birth, medical record number) against the blood component label and the
transfusion order. While checking vital signs, priming with normal saline, and
monitoring are all important steps in the transfusion process, they are secondary
to the verification of identity, which directly prevents the most common cause of
ABO incompatibility reactions.
4. A primigravida at 39 weeks gestation presents to the labor and delivery unit
with contractions every 3 to 4 minutes. A vaginal examination reveals that her
,cervix is 4 cm dilated, 90% effaced, and the fetal presenting part is at a station of
1. Which of the following phases of labor is the client experiencing?
A. Latent phase of the first stage.
B. Active phase of the first stage.
C. Transition phase of the first stage.
D. Second stage of labor.
Answer: B
Rationale: The first stage of labor is divided into three phases. The latent phase is
from 0 to approximately 4 cm dilation. The active phase, characterized by more
rapid cervical dilation, is generally from 4 cm to 7 cm dilation. The transition phase
is from 8 cm to 10 cm dilation. Since the client is 4 cm dilated and having regular
contractions, she is entering or is in the active phase. The second stage of labor
begins when the cervix is fully dilated (10 cm) and ends with the birth of the infant.
Station 1 indicates the presenting part is 1 cm below the ischial spines, which is
consistent with active labor.
5. A school nurse is teaching a group of adolescents about the prevention of
sexually transmitted infections. Which of the following statements by a student
indicates a need for further teaching?
A. "I should use a condom every time I have sex."
B. "I can get an infection even if I only have sex once."
C. "If I have no symptoms, I cannot pass an infection to someone else."
D. "I should get tested for STIs if I have a new partner."
Answer: C
Rationale: Many sexually transmitted infections are asymptomatic, meaning an
individual can be infected and contagious without exhibiting any signs or
symptoms. Chlamydia, gonorrhea, and human papillomavirus are examples of
infections that often present without symptoms. The statement "If I have no
symptoms, I cannot pass an infection to someone else" reflects a dangerous
misconception and indicates a need for further teaching. The other statements are
accurate and indicate an understanding of STI prevention and transmission.
, 6. A client is prescribed a low sodium diet for the management of hypertension.
Which of the following food choices should the nurse encourage the client to
avoid?
A. Fresh apples.
B. Baked chicken breast.
C. Canned tomato soup.
D. Unsalted almonds.
Answer: C
Rationale: Canned tomato soup is a processed food that is typically high in sodium
to enhance flavor and act as a preservative. A low sodium diet restricts sodium
intake to generally less than 2,300 mg per day, and often much lower. Fresh fruits,
unsalted nuts, and fresh, unseasoned meats are naturally low in sodium and are
appropriate choices for a client following a low sodium diet.
7. A nurse is assessing a client who has a chest tube attached to a water seal
drainage system. The nurse notes that the water in the water seal chamber is
gently bubbling. Which of the following actions should the nurse take?
A. Increase the suction to the prescribed level.
B. Notify the healthcare provider immediately.
C. Clamp the chest tube close to the insertion site.
D. Document the finding as an expected observation.
Answer: D
Rationale: In a wet suction water seal chest drainage system, intermittent
bubbling in the water seal chamber is an expected and normal finding. This
bubbling indicates that air is being evacuated from the pleural space and is exiting
through the water seal. Continuous, vigorous bubbling would indicate a leak in the
system. The nurse should document this normal finding and continue to monitor
the system. Clamping the tube should never be done without a specific order as it
could lead to a tension pneumothorax. Increasing suction or notifying the provider
is not indicated for this expected finding.
