Written by students who passed Immediately available after payment Read online or as PDF Wrong document? Swap it for free 4.6 TrustPilot
logo-home
Document preview thumbnail
Preview 4 out of 79 pages
Exam (elaborations)

NCLEX PN Actual Exam Test Bank With Complete Verified Questions And Correct Answers with Detailed Rationales |Already Graded A+||Brand New Guaranteed Pass

Document preview thumbnail
Preview 4 out of 79 pages

NCLEX PN Actual Exam Test Bank 2025 2026 With Complete Verified Questions And Correct Answers with Detailed Rationales |Already Graded A+||Brand New Guaranteed Pass a client is being prepared for a thoracentesis. the nurse should assist the client to which position for the procedure? a) sims' position, with the head of the bed flat b) prone, with the head turned to the side supported by a pillow c) lying in bed on the affected side, with the head of the bed elevated 45 degrees d) lying in bed on the unaffected side, with the head of the bed elevated 45 degrees - Correct Answer :d) lying in bed on the unaffected side, with the head of the bed elevated 45 degrees rationale to facilitate the removal of fluid from the chest, the client is positioned sitting on the edge of the bed, leaning over a bedside table, with the feet supported on a stool or lying in bed elevated 45 degrees (Fowler's position) the otehr options are incorrect the nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. which action should the nurse take? a) notify the rapid response team b) finish the suctioning as quickly as possible c) contact the respiratory department to suction the client d) discontinue suctioning until the client is stabilized and monitor vital signs NCLEX PN Actual Exam Test Bank A+ TEST BANK 2 - Correct Answer :d) discontinue suctioning until the client is stabilized and monitor vital signs rationale if a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. the nurse would also notify the registered nurse. it is also important to monitor the vital signs and the pulse oximetry. if the client's condition continues to deteriorate, then the respiratory department and HCP may need to be notified. there is no data in the question that indicates that the rapid response team needs to be notified. the nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. which findings should the nurse expect to note? select all that apply excessive bubbling in the water-seal chamber vigorous bubbling in the suction-control chamber 50 mL of drainage in the drainage-collection chamber the drainage system is maintained below the client's chest an occlusive dressing is in place over the chest tube insertion site fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation - Correct Answer :50 mL of drainage in the drainage-collection chamber // the drainage system is maintained below the client's chest // an occlusive dressing is in place over the chest-tube insertion site // fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation rationale the bubbling of water in the water-seal chamber indicates air drainage from the client. this is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. the fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. NCLEX PN Actual Exam Test Bank A+ TEST BANK 3 an absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. gentle (not vigorous) bubbling should be noted in the suction-control chamber. a total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hour is considered excessive and requires RN and HCP notification. the chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. positioning the drainage system below the client's chest allows gravity to drain the pleural space.

Content preview

NCLEX PN Actual Exam Test Bank
NCLEX PN Actual Exam Test Bank 2025-
2026 With Complete Verified Questions And
Correct Answers with Detailed Rationales
|Already Graded A+||Brand New Guaranteed
Pass
a client is being prepared for a thoracentesis. the nurse should assist the client to which position
for the procedure?

a) sims' position, with the head of the bed flat

b) prone, with the head turned to the side supported by a pillow

c) lying in bed on the affected side, with the head of the bed elevated 45 degrees

d) lying in bed on the unaffected side, with the head of the bed elevated 45 degrees

- Correct Answer :d) lying in bed on the unaffected side, with the head of the bed elevated 45
degrees

rationale
to facilitate the removal of fluid from the chest, the client is positioned sitting on the edge of the
bed, leaning over a bedside table, with the feet supported on a stool or lying in bed elevated 45
degrees (Fowler's position)
the otehr options are incorrect

the nurse is providing endotracheal suctioning to a client who is mechanically ventilated when
the client becomes restless and tachycardic.
which action should the nurse take?

a) notify the rapid response team

b) finish the suctioning as quickly as possible

c) contact the respiratory department to suction the client

d) discontinue suctioning until the client is stabilized and monitor vital signs

A+ TEST BANK 1

, NCLEX PN Actual Exam Test Bank

- Correct Answer :d) discontinue suctioning until the client is stabilized and monitor vital signs

rationale
if a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another
abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized.
the nurse would also notify the registered nurse.
it is also important to monitor the vital signs and the pulse oximetry.
if the client's condition continues to deteriorate, then the respiratory department and HCP may
need to be notified.
there is no data in the question that indicates that the rapid response team needs to be notified.

the nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client
who just returned from the recovery room after a thoracotomy with wedge resection.
which findings should the nurse expect to note?
select all that apply

excessive bubbling in the water-seal chamber

vigorous bubbling in the suction-control chamber

50 mL of drainage in the drainage-collection chamber

the drainage system is maintained below the client's chest

an occlusive dressing is in place over the chest tube insertion site

fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

- Correct Answer :50 mL of drainage in the drainage-collection chamber //
the drainage system is maintained below the client's chest // an occlusive dressing is in place
over the chest-tube insertion site // fluctuation of water in the tube of the water-seal chamber
during inhalation and exhalation

rationale
the bubbling of water in the water-seal chamber indicates air drainage from the client.
this is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may
occur during exhalation, coughing, or sneezing.
excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected
finding.
the fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is
expected.

A+ TEST BANK 2

, NCLEX PN Actual Exam Test Bank
an absence of fluctuation may indicate that the chest tube is obstructed, the lung has
reexpanded, or no more air is leaking into the pleural space.
gentle (not vigorous) bubbling should be noted in the suction-control chamber.
a total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the
recovery room; however, drainage of more than 70 to 100 mL/hour is considered excessive and
requires RN and HCP notification.
the chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from
entering the pleural space.
positioning the drainage system below the client's chest allows gravity to drain the pleural space.




the nurse is assigned to assist with caring for a client who has a chest tube.
A+ TEST BANK 3

, NCLEX PN Actual Exam Test Bank
the nurse notes fluctuations of the fluid level in the water-seal chamber.
based on this observation, which action would be appropriate?

a) empty the drainage

b) encourage the client to deep breathe

c) continue to monitor, because this is an expected finding

d) encourage the client to hold his or her breath periodically

- Correct Answer :c) continue to monitor, because this is an expected finding

rationale
the presence of fluctuations in the fluid level in the water-seal chamber indicates a patent
drainage system.
with normal breathing, the water level rises with inspiration and falls with expiration.
the apparatus and all connections must remain airtight at all times, and the drainage is never
emptied because of the risk of disruption in the closed system, which can result in lung collapse.
encouraging the client to deep breathe is unrelated to this observation.
the client is not told to hold his or her breath.

the nurse is assigned to assist the HCP with the removal of a chest tube.
the nurse should reinforce instructing the client to do which during this process?

a) stay very still

b) exhale forcefully

c) inhale and exhale quickly

d) perform Valsalva's maneuver

- Correct Answer :d) perform valsalva's maneuver

rationale
when the chest tube is removed, the client is asked to perform valsalva's maneuver (i.e. take a
deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight dressing is
taped in place.
an alternative instruction is to ask the client to take a deep breath and hold the breath while the
tube is removed.
the other options are incorrect client instructions

A+ TEST BANK 4

Document information

Uploaded on
September 2, 2025
Number of pages
79
Written in
2025/2026
Type
Exam (elaborations)
Contains
Questions & answers
$24.49

Wrong document? Swap it for free Within 14 days of purchase and before downloading, you can choose a different document. You can simply spend the amount again.
Written by students who passed
Immediately available after payment
Read online or as PDF

Seller avatar
Reputation scores are based on the amount of documents a seller has sold for a fee and the reviews they have received for those documents. There are three levels: Bronze, Silver and Gold. The better the reputation, the more your can rely on the quality of the sellers work.
laurenjames
3.6
(18)
Sold
100
Followers
17
Items
1561
Last sold
2 days ago


Why students choose Stuvia

Created by fellow students, verified by reviews

Quality you can trust: written by students who passed their tests and reviewed by others who've used these notes.

Didn't get what you expected? Choose another document

No worries! You can instantly pick a different document that better fits what you're looking for.

Pay as you like, start learning right away

No subscription, no commitments. Pay the way you're used to via credit card and download your PDF document instantly.

Student with book image

“Bought, downloaded, and aced it. It really can be that simple.”

Alisha Student

Working on your references?

Create accurate citations in APA, MLA and Harvard with our free citation generator.

Working on your references?

Frequently asked questions