Page 1 of 46
NCLEX-RN Test 1 Exam Questions And Rationale
Comprehensive 2026 Questions Exam Latest Version
Solved Questions & Answers Verified 100 %
For each finding below, click to specify if the finding is consistent with the
disease process of hemothorax or tension pneumothorax. Each finding may
support more than one disease process.
Hemothorax: results from the accumulation of blood loss in the pleural cavity --> loss
of intravascular blood vlolume: tachycardia, hypotension, unilateral diminished
breath sounds
Pneumothorax is characterized by air inside the pleural space, which disrupts the
negative pressure that maintains lung expansion, causing the lung to collapse either
partially or completely. Tension pneumothorax develops if air enters but cannot
escape the pleural space --> this trapping compresses the heart and great vessels
and displaces the midline structures (trachea) to the opposite side. Tension
pneumothorax: tachycardia, hypotension, subcutaneous emphysema/crepitus on
palpitation (air gets into the tissue under the skin), unilateral diminished breath
sounds (also tracheal deviation, hyperresonance to percussion)
Endoctracheal intubation would worsen the existing pneumothorax by delivering
positive pressure ventilation, which would increase intrathoracic pressure ==>
compress the heart and great vessels and lead to cardiac arrest.
Get all NCLEX for Exam preparation for 2026. The test banks include
comprehensive preparation and are designed to significantly enhance your
likelihood of passing all exams on the first attempt, with a success rate of up
to 97%. start preparing for your upcoming exams email
, Page 2 of 46
The charger nurse is responsible for making room assignments multiple
clients. Which pari of client assignments to a shared room is appropriate?
3. Client who had a bowel resection 1 day ago and client with asthma exacerbation.
When making room assignments, it is important to remember that a client with an
active or suspected infection should not be paired with a client who has a fresh
surgical wound or is immunocompromised. A client having an asthma exacerbation
does not have an infection and is not at risk for spreading infection to a client who
had a recent bowel resection surgery.
The clinic nurse is assessing a client who is being treated for depression and
suicidal ideation. Which client statement best indicates that the client is not
currently at risk for suicide?
2. "I plan to attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must be carefully
monitored for indications of increasing suicidal intent. During a client interview, the
nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely
to attempt death by suicide
The nurse is caring for a client who had an anterior wall myocardial infarction
2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the
client is in ventricular trigeminy. What is the nurse's priority intervention?
1. Administer potassium supplement
In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third
heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to
ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg,
, Page 3 of 46
ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia,
electrolyte imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L
[3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the
ectopy by administering the prescribed potassium replacement (Option 1). Health
care providers (HCPs) often prescribe electrolyte replacement algorithms to clients
at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a
contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight
<99.2 lb [45 kg]).
The nurse cares for a client with a terminal disease who created a do not
attempt resuscitation (DNAR) directive. The client stops breathing and loses
their pulse. The client's adult child states, "Please, do whatever you can to
save them!" Which intervention is appropriate?
3. Explain the client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive instructing that
CPR and other life-saving measures be withheld. With an advance directive in place,
the client's wishes should be followed, even if they conflict with the wishes of loved
ones
The nurse in the cardiac intensive care unit receives report on 4 clients. Which
client should the nurse assess first?
2. Client who underwent coronary artery stent placement via femoral approach 3
hours ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary
stent placement using the femoral approach is at increased risk for retroperitoneal
hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can
exacerbate potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma
formation, and diminished distal pulses can be early signs of bleeding into the
retroperitoneal space and require immediate intervention (eg, notify health care
provider, serial complete blood count, CT scan of the abdomen)
, Page 4 of 46
The nurse is reviewing the medical history of a client who has sustained a
right tibia/fibula fracture from a fall. The nurse identifies which finding as most
likely to hinder healing?
4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate circulation,
and age. A client with peripheral arterial disease has decreased perfusion to the
extremities due to atherosclerotic changes in the arteries. Without adequate
perfusion, the bone is not supplied with the oxygen and nutrients required for healing
Based on the nursing assessment progress notes, what is the correct staging
of the client's pressure injury? Click on the exhibit button for additional
information.
WRONG
2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion,
blister, or shallow crater). The skin blisters or forms an open sore, and the area
around the sore may be red and irritated. (shallow, open ulcer, red-pink wound with
no sloughing and possible intact or ruptured blister)
Stage 1: Intact skin with nonblanchable redness
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the
dermis or epidermis; the wound bed is red or pink and may be shiny or dry
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle,
or bone; tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or
eschar (scabbing, dead tissue) may be present; undermining and tunneling may be
present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
A client with type 1 diabetes mellitus has prescriptions for NPH insulin and
regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9
mmol/L), and the breakfast tray has arrived. What action should the nurse
take? Click the exhibit button for additional information.
NCLEX-RN Test 1 Exam Questions And Rationale
Comprehensive 2026 Questions Exam Latest Version
Solved Questions & Answers Verified 100 %
For each finding below, click to specify if the finding is consistent with the
disease process of hemothorax or tension pneumothorax. Each finding may
support more than one disease process.
Hemothorax: results from the accumulation of blood loss in the pleural cavity --> loss
of intravascular blood vlolume: tachycardia, hypotension, unilateral diminished
breath sounds
Pneumothorax is characterized by air inside the pleural space, which disrupts the
negative pressure that maintains lung expansion, causing the lung to collapse either
partially or completely. Tension pneumothorax develops if air enters but cannot
escape the pleural space --> this trapping compresses the heart and great vessels
and displaces the midline structures (trachea) to the opposite side. Tension
pneumothorax: tachycardia, hypotension, subcutaneous emphysema/crepitus on
palpitation (air gets into the tissue under the skin), unilateral diminished breath
sounds (also tracheal deviation, hyperresonance to percussion)
Endoctracheal intubation would worsen the existing pneumothorax by delivering
positive pressure ventilation, which would increase intrathoracic pressure ==>
compress the heart and great vessels and lead to cardiac arrest.
Get all NCLEX for Exam preparation for 2026. The test banks include
comprehensive preparation and are designed to significantly enhance your
likelihood of passing all exams on the first attempt, with a success rate of up
to 97%. start preparing for your upcoming exams email
, Page 2 of 46
The charger nurse is responsible for making room assignments multiple
clients. Which pari of client assignments to a shared room is appropriate?
3. Client who had a bowel resection 1 day ago and client with asthma exacerbation.
When making room assignments, it is important to remember that a client with an
active or suspected infection should not be paired with a client who has a fresh
surgical wound or is immunocompromised. A client having an asthma exacerbation
does not have an infection and is not at risk for spreading infection to a client who
had a recent bowel resection surgery.
The clinic nurse is assessing a client who is being treated for depression and
suicidal ideation. Which client statement best indicates that the client is not
currently at risk for suicide?
2. "I plan to attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must be carefully
monitored for indications of increasing suicidal intent. During a client interview, the
nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely
to attempt death by suicide
The nurse is caring for a client who had an anterior wall myocardial infarction
2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the
client is in ventricular trigeminy. What is the nurse's priority intervention?
1. Administer potassium supplement
In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third
heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to
ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg,
, Page 3 of 46
ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia,
electrolyte imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L
[3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the
ectopy by administering the prescribed potassium replacement (Option 1). Health
care providers (HCPs) often prescribe electrolyte replacement algorithms to clients
at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a
contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight
<99.2 lb [45 kg]).
The nurse cares for a client with a terminal disease who created a do not
attempt resuscitation (DNAR) directive. The client stops breathing and loses
their pulse. The client's adult child states, "Please, do whatever you can to
save them!" Which intervention is appropriate?
3. Explain the client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive instructing that
CPR and other life-saving measures be withheld. With an advance directive in place,
the client's wishes should be followed, even if they conflict with the wishes of loved
ones
The nurse in the cardiac intensive care unit receives report on 4 clients. Which
client should the nurse assess first?
2. Client who underwent coronary artery stent placement via femoral approach 3
hours ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary
stent placement using the femoral approach is at increased risk for retroperitoneal
hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can
exacerbate potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma
formation, and diminished distal pulses can be early signs of bleeding into the
retroperitoneal space and require immediate intervention (eg, notify health care
provider, serial complete blood count, CT scan of the abdomen)
, Page 4 of 46
The nurse is reviewing the medical history of a client who has sustained a
right tibia/fibula fracture from a fall. The nurse identifies which finding as most
likely to hinder healing?
4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate circulation,
and age. A client with peripheral arterial disease has decreased perfusion to the
extremities due to atherosclerotic changes in the arteries. Without adequate
perfusion, the bone is not supplied with the oxygen and nutrients required for healing
Based on the nursing assessment progress notes, what is the correct staging
of the client's pressure injury? Click on the exhibit button for additional
information.
WRONG
2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion,
blister, or shallow crater). The skin blisters or forms an open sore, and the area
around the sore may be red and irritated. (shallow, open ulcer, red-pink wound with
no sloughing and possible intact or ruptured blister)
Stage 1: Intact skin with nonblanchable redness
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the
dermis or epidermis; the wound bed is red or pink and may be shiny or dry
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle,
or bone; tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or
eschar (scabbing, dead tissue) may be present; undermining and tunneling may be
present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
A client with type 1 diabetes mellitus has prescriptions for NPH insulin and
regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9
mmol/L), and the breakfast tray has arrived. What action should the nurse
take? Click the exhibit button for additional information.
