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Review for NCLEX-RN
Examination (1 Year) 2026 |
Complete NCLEX Prep
Guide
|Graded A+ | Guaranteed
success|
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,A nurse on the telemetry unit is caring for a client who Answer: A
has had a myocardial infarction and is now attached to a Rationale: This pattern indicates ventricular fibrillation (VF). Clients who have
cardiac monitor. The nurse, monitoring the client's cardiac sustained a myocardial infarction are at great risk for VF. With the onset of VF the
rhythm, notes the rhythm depicted in the image. Which of client feels faint, then immediately loses consciousness and becomes pulseless
the following nursing actions should the nurse take? and apneic. There is no blood pressure, and heart sounds are absent. The goals of
(Rhythm is continuous up and down in pic) treatment are to terminate VF promptly and convert it to an organized rhythm.
A) Calling the rapid response team Because defibrillation is the immediate treatment, the nurse must call the rapid
B) Preparing the client for cardioversion response team and initiate cardiopulmonary resuscitation. The client would not be
C) Asking the client to bear down and cough able to bear down or cough. Cardioversion is a synchronized countershock that
D) Preparing to administer diltiazem (Cardiazem) may be performed in emergencies for unstable ventricular or supraventricular
tachydysrhythmias or electively for stable tachydysrhythmias that are resistant to
medical therapies such as the administration of diltiazem (Cardiazem).
A nurse developing a plan of care for a client with a Answer: B
spinal cord injury includes measures to prevent Rationale: The most frequent causes of autonomic dysreflexia are a distended
autonomic dysreflexia (hyperreflexia). Which of the bladder and impacted feces in the rectum. Straight catheterization should be
following interventions does the nurse incorporate into performed every 4 to 6 hours, and the Foley catheter should be checked
the plan to prevent this complication? frequently to prevent kinks in the tubing. Constipation and fecal impaction are
A) Keeping a fan running in the client's room other causes, so maintaining bowel regularity is important. Other causes include
B) Keeping the linens wrinkle-free under the client stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care
C) Limiting bladder catheterization to once every 12 in such a way as to minimize risk in these areas.
hours
D) Avoiding the administration of enemas and rectal
suppositories
A nurse provides home care instructions to a client who Answer: C
has been fitted with a halo device to treat a cervical Rationale: The client should cleanse the skin under the lambs-wool liner each day
fracture. Which statement by the client indicates the need to prevent rashes or sores. Powder or lotions should be used only sparingly or
for further instruction? not at all because they may cake, resulting in skin irritation. The client should
A) "I need to get more fluids and fiber into my diet." increase intake of fluid and fiber to help prevent constipation. Food should be cut
B) "I should cut my food into small pieces before I eat." into small pieces to facilitate chewing and swallowing. The client should also use a
C) "I need to put powder under the vest twice a day to straw for drinking. The pin sites should be checked daily for signs of infection.
prevent sweating."
D) "I have to check the pin sites every day and watch for
signs of infection."
A nurse is caring for client with increased intracranial Answer: D
pressure (ICP). In which position should the nurse Rationale: The client with increased ICP should be positioned with the head in a
maintain the client? neutral midline position. It is the responsibility of the nurse to ensure that all those
A) Supine, with the head extended delivering care to the client maintain the proper positioning. The client should
B) Side-lying, with the neck flexed avoid flexing or extending the neck or turning the neck side to side. The head of
C) Supine, with the head turned to the side the bed should be raised to 30 to 45 degrees. Use of proper positioning
D) Head midline and elevated 30 to 45 degrees promotes venous drainage from the cranium to keep ICP down.
A client with a basilar skull fracture has clear fluid leaking Answer: B
from the ears. The nurse should: Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may
A) Assess the clear fluid for protein accompany basilar skull fracture. CSF can be distinguished from other body fluids
B) Check the clear fluid for the presence of glucose because it will separate into bloody and yellow concentric rings on dressing
C) Place cotton balls or dry gauze loosely in the ears material, a phenomenon referred to as the halo sign. It also tests positive for
D) Use an otoscope to assess the tympanic membrane glucose. CSF does not contain protein. The presence of CSF indicates a disruption
for rupture in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an
otoscope into the ear puts the client at risk for infection.
, A nurse is caring for a client who has just undergone Answer: A
cardioversion. Which of the following interventions is the Rationale: Nursing responsibilities after cardioversion include maintenance of a
nurse's priority after this procedure? patent airway, oxygen administration, assessment of vital signs and level of
A) Administering oxygen consciousness, and detection of dysrhythmias. The priority nursing intervention
B) Monitoring the blood pressure here is administering oxygen.
C) Administering antidysrhythmic medications
D) Monitoring the client's level of consciousness
A client with diabetes mellitus who is scheduled to have Answer: B
blood drawn for determination of the glycosylated Rationale: The HbA1C reading provides an indication of glycemic control over the
hemoglobin (HbA1C) level asks the nurse why the test is preceding 3 months. An HbA1C value of less than 7% indicates good glycemic
necessary if he is performing blood glucose monitoring control. When increases in the blood glucose occur, some glucose molecules
at home. The nurse tells the client that this test is used attach themselves to red blood cells (RBCs) and remain there for the life of the
specifically to: RBCs. Therefore a high value on this test is correlated with a high blood glucose
A) Detect diabetic complications level, indicating poor long-term control of blood glucose, which often leads to
B) Assess long-term glycemic control the development of complications in the client with diabetes mellitus. The other
C) Determine whether the client is at risk for options are not purposes for this test.
hypoglycemia
D) Determine whether the prescribed insulin dosage is
adequate
A nurse caring for a client with AIDS is monitoring the Answer(s): B, D, E
client for signs of complications. Which of the following Rationale: Pneumocystis jiroveci pneumonia is a very common and severe
findings would cause the nurse to suspect infection with opportunistic infection affecting the client with AIDS. Clinical manifestations
Pneumocystis jiroveci? Select all that apply. include dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia,
A) Diarrhea weight loss, and tachypnea. Persons with advanced disease may exhibit crackles,
B) Tachypnea decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not
C) Pedal edema associated with this infection.
D) Intermittent fever
E) Dyspnea when ambulating
F) Expectoration of frothy mucus
Zidovudine (AZT, Retrovir) is prescribed for a client with Answer: C
AIDS. The nurse tells the client that it is important to Rationale: Zidovudine is an antiviral medication. Common side effects include
report back to the clinic as scheduled for follow-up: agranulocytopenia and anemia. The nurse carefully monitors CBC results for these
A) Blood glucose checks changes. With early infection or in the client who is asymptomatic, a CBC is usually
B) Blood pressure checks performed monthly for 3 months, then every 3 months thereafter. In clients with
C) Complete blood counts (CBCs) advanced disease, a CBC is usually performed every 2 weeks for the first 2
D) Electrocardiographic (ECG) studies months and then once a month if the medication is tolerated well. This medication
does not affect the blood glucose level, blood pressure, or cardiac status.
After a nonimmunocompromised client undergoes a Answer: B
Mantoux test for tuberculosis (TB) infection, an area of Rationale: An area of induration of less than 10 mm is considered a negative result.
induration 6 mm wide develops. The client asks the nurse An area of induration (not redness) measuring 10 mm or more in diameter 48 to 72
what this result means. The nurse's best response is: hours after injection in a client without immunosuppressive disease indicates
A) "We'll have to repeat the test, because the result is exposure to and possible infection with TB. A reaction of 5 mm or greater is
inconclusive." considered positive in immunocompromised individuals. A positive reaction does
B) "The swollen area is small, so that means your test not mean that active disease is present but instead indicates exposure to TB or the
result is negative." presence of inactive (dormant) TB. Further testing, including a chest x-ray and
C) "You've been exposed to tuberculosis, so you'll need sputum culture, would be required if the reaction were positive.
to have a chest x-ray."
D) "You need to get started on medication right away,
because you've got tuberculosis."
Review for NCLEX-RN
Examination (1 Year) 2026 |
Complete NCLEX Prep
Guide
|Graded A+ | Guaranteed
success|
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,A nurse on the telemetry unit is caring for a client who Answer: A
has had a myocardial infarction and is now attached to a Rationale: This pattern indicates ventricular fibrillation (VF). Clients who have
cardiac monitor. The nurse, monitoring the client's cardiac sustained a myocardial infarction are at great risk for VF. With the onset of VF the
rhythm, notes the rhythm depicted in the image. Which of client feels faint, then immediately loses consciousness and becomes pulseless
the following nursing actions should the nurse take? and apneic. There is no blood pressure, and heart sounds are absent. The goals of
(Rhythm is continuous up and down in pic) treatment are to terminate VF promptly and convert it to an organized rhythm.
A) Calling the rapid response team Because defibrillation is the immediate treatment, the nurse must call the rapid
B) Preparing the client for cardioversion response team and initiate cardiopulmonary resuscitation. The client would not be
C) Asking the client to bear down and cough able to bear down or cough. Cardioversion is a synchronized countershock that
D) Preparing to administer diltiazem (Cardiazem) may be performed in emergencies for unstable ventricular or supraventricular
tachydysrhythmias or electively for stable tachydysrhythmias that are resistant to
medical therapies such as the administration of diltiazem (Cardiazem).
A nurse developing a plan of care for a client with a Answer: B
spinal cord injury includes measures to prevent Rationale: The most frequent causes of autonomic dysreflexia are a distended
autonomic dysreflexia (hyperreflexia). Which of the bladder and impacted feces in the rectum. Straight catheterization should be
following interventions does the nurse incorporate into performed every 4 to 6 hours, and the Foley catheter should be checked
the plan to prevent this complication? frequently to prevent kinks in the tubing. Constipation and fecal impaction are
A) Keeping a fan running in the client's room other causes, so maintaining bowel regularity is important. Other causes include
B) Keeping the linens wrinkle-free under the client stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care
C) Limiting bladder catheterization to once every 12 in such a way as to minimize risk in these areas.
hours
D) Avoiding the administration of enemas and rectal
suppositories
A nurse provides home care instructions to a client who Answer: C
has been fitted with a halo device to treat a cervical Rationale: The client should cleanse the skin under the lambs-wool liner each day
fracture. Which statement by the client indicates the need to prevent rashes or sores. Powder or lotions should be used only sparingly or
for further instruction? not at all because they may cake, resulting in skin irritation. The client should
A) "I need to get more fluids and fiber into my diet." increase intake of fluid and fiber to help prevent constipation. Food should be cut
B) "I should cut my food into small pieces before I eat." into small pieces to facilitate chewing and swallowing. The client should also use a
C) "I need to put powder under the vest twice a day to straw for drinking. The pin sites should be checked daily for signs of infection.
prevent sweating."
D) "I have to check the pin sites every day and watch for
signs of infection."
A nurse is caring for client with increased intracranial Answer: D
pressure (ICP). In which position should the nurse Rationale: The client with increased ICP should be positioned with the head in a
maintain the client? neutral midline position. It is the responsibility of the nurse to ensure that all those
A) Supine, with the head extended delivering care to the client maintain the proper positioning. The client should
B) Side-lying, with the neck flexed avoid flexing or extending the neck or turning the neck side to side. The head of
C) Supine, with the head turned to the side the bed should be raised to 30 to 45 degrees. Use of proper positioning
D) Head midline and elevated 30 to 45 degrees promotes venous drainage from the cranium to keep ICP down.
A client with a basilar skull fracture has clear fluid leaking Answer: B
from the ears. The nurse should: Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may
A) Assess the clear fluid for protein accompany basilar skull fracture. CSF can be distinguished from other body fluids
B) Check the clear fluid for the presence of glucose because it will separate into bloody and yellow concentric rings on dressing
C) Place cotton balls or dry gauze loosely in the ears material, a phenomenon referred to as the halo sign. It also tests positive for
D) Use an otoscope to assess the tympanic membrane glucose. CSF does not contain protein. The presence of CSF indicates a disruption
for rupture in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an
otoscope into the ear puts the client at risk for infection.
, A nurse is caring for a client who has just undergone Answer: A
cardioversion. Which of the following interventions is the Rationale: Nursing responsibilities after cardioversion include maintenance of a
nurse's priority after this procedure? patent airway, oxygen administration, assessment of vital signs and level of
A) Administering oxygen consciousness, and detection of dysrhythmias. The priority nursing intervention
B) Monitoring the blood pressure here is administering oxygen.
C) Administering antidysrhythmic medications
D) Monitoring the client's level of consciousness
A client with diabetes mellitus who is scheduled to have Answer: B
blood drawn for determination of the glycosylated Rationale: The HbA1C reading provides an indication of glycemic control over the
hemoglobin (HbA1C) level asks the nurse why the test is preceding 3 months. An HbA1C value of less than 7% indicates good glycemic
necessary if he is performing blood glucose monitoring control. When increases in the blood glucose occur, some glucose molecules
at home. The nurse tells the client that this test is used attach themselves to red blood cells (RBCs) and remain there for the life of the
specifically to: RBCs. Therefore a high value on this test is correlated with a high blood glucose
A) Detect diabetic complications level, indicating poor long-term control of blood glucose, which often leads to
B) Assess long-term glycemic control the development of complications in the client with diabetes mellitus. The other
C) Determine whether the client is at risk for options are not purposes for this test.
hypoglycemia
D) Determine whether the prescribed insulin dosage is
adequate
A nurse caring for a client with AIDS is monitoring the Answer(s): B, D, E
client for signs of complications. Which of the following Rationale: Pneumocystis jiroveci pneumonia is a very common and severe
findings would cause the nurse to suspect infection with opportunistic infection affecting the client with AIDS. Clinical manifestations
Pneumocystis jiroveci? Select all that apply. include dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia,
A) Diarrhea weight loss, and tachypnea. Persons with advanced disease may exhibit crackles,
B) Tachypnea decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not
C) Pedal edema associated with this infection.
D) Intermittent fever
E) Dyspnea when ambulating
F) Expectoration of frothy mucus
Zidovudine (AZT, Retrovir) is prescribed for a client with Answer: C
AIDS. The nurse tells the client that it is important to Rationale: Zidovudine is an antiviral medication. Common side effects include
report back to the clinic as scheduled for follow-up: agranulocytopenia and anemia. The nurse carefully monitors CBC results for these
A) Blood glucose checks changes. With early infection or in the client who is asymptomatic, a CBC is usually
B) Blood pressure checks performed monthly for 3 months, then every 3 months thereafter. In clients with
C) Complete blood counts (CBCs) advanced disease, a CBC is usually performed every 2 weeks for the first 2
D) Electrocardiographic (ECG) studies months and then once a month if the medication is tolerated well. This medication
does not affect the blood glucose level, blood pressure, or cardiac status.
After a nonimmunocompromised client undergoes a Answer: B
Mantoux test for tuberculosis (TB) infection, an area of Rationale: An area of induration of less than 10 mm is considered a negative result.
induration 6 mm wide develops. The client asks the nurse An area of induration (not redness) measuring 10 mm or more in diameter 48 to 72
what this result means. The nurse's best response is: hours after injection in a client without immunosuppressive disease indicates
A) "We'll have to repeat the test, because the result is exposure to and possible infection with TB. A reaction of 5 mm or greater is
inconclusive." considered positive in immunocompromised individuals. A positive reaction does
B) "The swollen area is small, so that means your test not mean that active disease is present but instead indicates exposure to TB or the
result is negative." presence of inactive (dormant) TB. Further testing, including a chest x-ray and
C) "You've been exposed to tuberculosis, so you'll need sputum culture, would be required if the reaction were positive.
to have a chest x-ray."
D) "You need to get started on medication right away,
because you've got tuberculosis."
