NCLEX PN Exam 2026 (Full Actual Exam) |
Complete Questions and Correct Answers
with Rationales | Latest Update
During a neurologic examination, the notes the client's upper extremities
are flexed, and internally rotated with plantar flexion of the lower
extremities. What should the nurse document?
A. Contractures
B. Decorticate posturing
C. Decerebrate posturing
D. Tetany ---------CORRECT ANSWER-----------------B. Decorticate
posturing
Rationale: Decorticate posturing is a sign indicating that the client is
neurologically decompensating. The client's upper extremities will be
flexed, and internally rotated with plantar flexion of the lower
extremities.
During a neurologic assessment, a client demonstrates swaying with eyes
closed. Based on this finding, which condition should the nurse suspect?
A. Positive Babinski
B. Positive Romberg sign
C. Positive Weber test
D. Negative Romberg ---------CORRECT ANSWER-----------------B. Positive
Romberg sign
Rationale: Swaying with eyes closed is indicative of a positive
Romberg sign indicating a condition known as proprioception.
,During the initial 24 hours after an above-the-knee amputation, the nurse
performs which priority action to properly manage the surgical site?
A. Elevate the residual limb
B. Loosen the dressing every 4 hours
C. Maintain the residual limb in a dependent position
D. Change the dressing as often as needed ---------CORRECT ANSWER---
--------------A. Elevate the residual limb
Rationale: Elevating the limb during the first 24 hours facilitates
venous return, decreases swelling and promotes comfort.
A client with a right arm cast for fractured humerus states, "I haven't been
able to straighten the fingers on my right hand since this morning." What
action should the nurse take?
A. Assess neurovascular status to the hand
B. Ask the client to massage the fingers
C. Encourage the client to take the prescribed analgesic
D. Elevate the right arm on a pillow to reduce edema ---------CORRECT
ANSWER-----------------A. Assess neurovascular status to the hand
Rationale: This finding is suggestive of neurological injury as a result
of pressure on nerves and soft tissue because of swelling.
Which is the most common cause of postoperative hypoxemia?
A. Alveolar collapse
B. Bronchospasm
C. Aspiration
,D. Pulmonary Edema ---------CORRECT ANSWER-----------------A. Alveolar
collapse
Rationale: The most common cause of hypoxemia after surgery is
atelectasis.
Which client has the highest risk for a bacteremia?
A. Client with a peripherally inserted central catheter (PICC) line
B. Client with a central venous catheter (CVC)
C.Client with an implanted infusion port
D. Client with a peripherally inserted intravenous line ---------CORRECT
ANSWER-----------------B. Client with a central venous catheter (CVC)
Rationale: Central venous catheter insertion are placed into a vein in
the neck or chest with the tip resting in the superior vena cava and
carry the highest risk for bacterial infection of the bloodstream.
What is the priority nursing action after a subtotal thyroidectomy?
A. Airway obstruction
B. Hemorrhage
C. Tetany
D. Edema ---------CORRECT ANSWER-----------------A. Airway obstruction
Rationale: A priority nursing action after a subtotal thyroidectomy is
airway assessment because airway obstruction may occur
postoperatively. It is a medical emergency and resuscitative
equipment must be readily available in the client's room.
, A patient with chronic low back pain is on extended release morphine twice
a day for pain control. The patient has a pain contract in place. He requests
a refill for his pain medication. Upon review of his request for pain
medication refills you note that he has requested his pain medication at
least 10 days later than expected the last three times. You have the patient
come in to assess his use of the pain medication. He reports that he takes
the pain medication once a day and he only uses the second dose if
needed. What do you anticipate next?
A. Authorization of a refill for his medication
B.Instruction for use of extended release medication, review of the pain
contract, decrease in dose to once a day
C. Discontinuation of medication
D. Change in the orders for one tablet of the extended release morphine
daily with a second tablet daily as needed ---------CORRECT ANSWER------
-----------C. Discontinuation of medication
Extended release narcotics for chronic pain are meant to be taken on
schedule and not as needed. A pain contract typically indicates that
the narcotic will be taken as prescribed.
Among the reasons for a primary risk assessment for the development of
cancer in women are all of the following EXCEPT:
A. Detecting a trait or characteristic of cancer can be associated with the
development of cancer
B. Identifying the client who has started menses before age 12 as a risk
factor in the development of cancer
C. Recognizing that living in certain areas of the United States have been
found to be conclusive risk factors for developing cancer
D. Understanding that the discovery of a family history that includes at least
one family member who has been diagnosed with cancer as a risk factor ---
------CORRECT ANSWER-----------------C. Recognizing that living in certain
Complete Questions and Correct Answers
with Rationales | Latest Update
During a neurologic examination, the notes the client's upper extremities
are flexed, and internally rotated with plantar flexion of the lower
extremities. What should the nurse document?
A. Contractures
B. Decorticate posturing
C. Decerebrate posturing
D. Tetany ---------CORRECT ANSWER-----------------B. Decorticate
posturing
Rationale: Decorticate posturing is a sign indicating that the client is
neurologically decompensating. The client's upper extremities will be
flexed, and internally rotated with plantar flexion of the lower
extremities.
During a neurologic assessment, a client demonstrates swaying with eyes
closed. Based on this finding, which condition should the nurse suspect?
A. Positive Babinski
B. Positive Romberg sign
C. Positive Weber test
D. Negative Romberg ---------CORRECT ANSWER-----------------B. Positive
Romberg sign
Rationale: Swaying with eyes closed is indicative of a positive
Romberg sign indicating a condition known as proprioception.
,During the initial 24 hours after an above-the-knee amputation, the nurse
performs which priority action to properly manage the surgical site?
A. Elevate the residual limb
B. Loosen the dressing every 4 hours
C. Maintain the residual limb in a dependent position
D. Change the dressing as often as needed ---------CORRECT ANSWER---
--------------A. Elevate the residual limb
Rationale: Elevating the limb during the first 24 hours facilitates
venous return, decreases swelling and promotes comfort.
A client with a right arm cast for fractured humerus states, "I haven't been
able to straighten the fingers on my right hand since this morning." What
action should the nurse take?
A. Assess neurovascular status to the hand
B. Ask the client to massage the fingers
C. Encourage the client to take the prescribed analgesic
D. Elevate the right arm on a pillow to reduce edema ---------CORRECT
ANSWER-----------------A. Assess neurovascular status to the hand
Rationale: This finding is suggestive of neurological injury as a result
of pressure on nerves and soft tissue because of swelling.
Which is the most common cause of postoperative hypoxemia?
A. Alveolar collapse
B. Bronchospasm
C. Aspiration
,D. Pulmonary Edema ---------CORRECT ANSWER-----------------A. Alveolar
collapse
Rationale: The most common cause of hypoxemia after surgery is
atelectasis.
Which client has the highest risk for a bacteremia?
A. Client with a peripherally inserted central catheter (PICC) line
B. Client with a central venous catheter (CVC)
C.Client with an implanted infusion port
D. Client with a peripherally inserted intravenous line ---------CORRECT
ANSWER-----------------B. Client with a central venous catheter (CVC)
Rationale: Central venous catheter insertion are placed into a vein in
the neck or chest with the tip resting in the superior vena cava and
carry the highest risk for bacterial infection of the bloodstream.
What is the priority nursing action after a subtotal thyroidectomy?
A. Airway obstruction
B. Hemorrhage
C. Tetany
D. Edema ---------CORRECT ANSWER-----------------A. Airway obstruction
Rationale: A priority nursing action after a subtotal thyroidectomy is
airway assessment because airway obstruction may occur
postoperatively. It is a medical emergency and resuscitative
equipment must be readily available in the client's room.
, A patient with chronic low back pain is on extended release morphine twice
a day for pain control. The patient has a pain contract in place. He requests
a refill for his pain medication. Upon review of his request for pain
medication refills you note that he has requested his pain medication at
least 10 days later than expected the last three times. You have the patient
come in to assess his use of the pain medication. He reports that he takes
the pain medication once a day and he only uses the second dose if
needed. What do you anticipate next?
A. Authorization of a refill for his medication
B.Instruction for use of extended release medication, review of the pain
contract, decrease in dose to once a day
C. Discontinuation of medication
D. Change in the orders for one tablet of the extended release morphine
daily with a second tablet daily as needed ---------CORRECT ANSWER------
-----------C. Discontinuation of medication
Extended release narcotics for chronic pain are meant to be taken on
schedule and not as needed. A pain contract typically indicates that
the narcotic will be taken as prescribed.
Among the reasons for a primary risk assessment for the development of
cancer in women are all of the following EXCEPT:
A. Detecting a trait or characteristic of cancer can be associated with the
development of cancer
B. Identifying the client who has started menses before age 12 as a risk
factor in the development of cancer
C. Recognizing that living in certain areas of the United States have been
found to be conclusive risk factors for developing cancer
D. Understanding that the discovery of a family history that includes at least
one family member who has been diagnosed with cancer as a risk factor ---
------CORRECT ANSWER-----------------C. Recognizing that living in certain
