NCLEX-PN REVIEW EXAM 2025/2026
QUESTIONS AND ANSWERS 100% PASS
The nurse is instructing a client with Addison's disease about a newly prescribed medication,
fludrocortisone acetate (Florinef). Which statement by the client indicates a need for further
teaching? - ANS "I will be glad to gain weight."
Rationale: The client should notify the health care provider of weight gain. The client should
take oral drugs with food or milk. The client should wear a Medic-Alert bracelet. Fludrocortisone
acetate (Florinef) should not be stopped abruptly but should be tapered down.
A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate
that the condition is worsening? - ANS Decreased wheezing
Rationale:Decreased wheezing in a child who is not improving clinically may be interpreted
incorrectly as a positive sign, when in fact it may signal an inability to move air. A "silent chest"
is an ominous sign during an asthma episode. With treatment, increased wheezing may actually
signal that the child's condition is improving. Warm, dry skin indicates an improvement in the
condition because the child is normally diaphoretic during exacerbation. The normal pulse rate
in a 10-year-old is 70 to 110 beats per minute.
The nurse is assigned to assist in caring for a client with a chest tube drainage system. In
planning for the client, the nurse makes certain that what equipment is available, in the event
that the drainage system needs to be changed? - ANS Rubber-shod clamps
Rationale:
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,If the drainage system needs to be changed, the registered nurse will use rubber-shod clamps to
clamp the tube near the client's chest while the drainage system is changed. This procedure is
done quickly and with the assistance of another nurse. The clamps are removed immediately
after reconnection of the new drainage system. Agency procedure regarding clamping chest
tubes is always followed, and a health care provider's prescription for clamping the tube may be
required. If clamps must be used, the best time to apply them is after expiration. An occlusive
dressing such as a petrolatum (Vaseline) gauze dressing is used when a chest tube is removed.
Options 2 and 4 are not needed for changing a drainage system.
A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the
LPN notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5
days. Which would be appropriate as the initial nursing action? - ANS Notify the registered
nurse of the findings.
Rationale:
The client is showing signs of fluid retention and possible excess fluid intake. Crackles, edema,
and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces. The
problem may or may not be related to the parenteral nutrition. Other possible causes of fluid
retention include impaired respiratory and cardiovascular function, impaired kidney function, or
a combination of factors. The nurse needs to notify the registered nurse of the findings. The
registered nurse will then notify the health care provider for further prescriptions. Option 2 will
have little, if any, effect on peripheral edema and weight gain. Option 3 infers that a diuretic will
help the situation, and it is possible that the health care provider will prescribe a diuretic;
however, the health care provider needs to be aware of the change in the physical condition of
the client. The nurse should not increase or decrease the rate of parenteral nutrition infusions
without a health care provider's prescription to do so.
The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the
client is experiencing which heart rhythm? Refer to figure. - ANS Atrial fibrillation
Diagram of normal sinus rhythm as seen on ECG. In atrial fibrillation the P waves, which
represent depolarization of the top of the heart, are absent
The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy.
A wound drain is in place in the abdominal wound. Which nursing action would be appropriate
during the dressing change? - ANS Checking the wound site for drainage from the drain
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, Rationale:
The wound site needs to be checked for drainage from the drain; the drainage can excoriate the
skin. Usually the drainage from the wound is pale, red, and watery. Active bleeding is bright red.
Aseptic technique must be used when changing the dressing to avoid contamination of the
wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit
for the fluid and blood to promote healing. The drainage needs to flow freely, and there should
be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of drainage. The
tube is not advanced.
When caring for a client who is having clear drainage from his nares after transsphenoidal
hypophysectomy, which action by the nurse is essential? - ANS Test the drainage for glucose.
Rationale:
After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a
cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for
glucose, indicating the presence of CSF. The head of the bed should not be lowered to prevent
increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture.
Continuing to observe the drainage without taking action could result in a serious complication.
A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy.
Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement
protective isolation procedures. Which interventions should the nurse initiate? Select all that
apply. - ANS 1. Place the child on a low-bacteria diet.
2. Change dressings using sterile technique.
3. Perform meticulous hand washing before caring for the child.
Rationale:
For the hospitalized neutropenic child, flowers or plants should not be kept in the room because
standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are
very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should
be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet.
Dressings are always changed with sterile technique. Not all visitors need to be restricted, but
anyone who is ill should not be allowed in the child's room Meticulous hand washing is required
before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
QUESTIONS AND ANSWERS 100% PASS
The nurse is instructing a client with Addison's disease about a newly prescribed medication,
fludrocortisone acetate (Florinef). Which statement by the client indicates a need for further
teaching? - ANS "I will be glad to gain weight."
Rationale: The client should notify the health care provider of weight gain. The client should
take oral drugs with food or milk. The client should wear a Medic-Alert bracelet. Fludrocortisone
acetate (Florinef) should not be stopped abruptly but should be tapered down.
A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate
that the condition is worsening? - ANS Decreased wheezing
Rationale:Decreased wheezing in a child who is not improving clinically may be interpreted
incorrectly as a positive sign, when in fact it may signal an inability to move air. A "silent chest"
is an ominous sign during an asthma episode. With treatment, increased wheezing may actually
signal that the child's condition is improving. Warm, dry skin indicates an improvement in the
condition because the child is normally diaphoretic during exacerbation. The normal pulse rate
in a 10-year-old is 70 to 110 beats per minute.
The nurse is assigned to assist in caring for a client with a chest tube drainage system. In
planning for the client, the nurse makes certain that what equipment is available, in the event
that the drainage system needs to be changed? - ANS Rubber-shod clamps
Rationale:
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,If the drainage system needs to be changed, the registered nurse will use rubber-shod clamps to
clamp the tube near the client's chest while the drainage system is changed. This procedure is
done quickly and with the assistance of another nurse. The clamps are removed immediately
after reconnection of the new drainage system. Agency procedure regarding clamping chest
tubes is always followed, and a health care provider's prescription for clamping the tube may be
required. If clamps must be used, the best time to apply them is after expiration. An occlusive
dressing such as a petrolatum (Vaseline) gauze dressing is used when a chest tube is removed.
Options 2 and 4 are not needed for changing a drainage system.
A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the
LPN notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5
days. Which would be appropriate as the initial nursing action? - ANS Notify the registered
nurse of the findings.
Rationale:
The client is showing signs of fluid retention and possible excess fluid intake. Crackles, edema,
and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces. The
problem may or may not be related to the parenteral nutrition. Other possible causes of fluid
retention include impaired respiratory and cardiovascular function, impaired kidney function, or
a combination of factors. The nurse needs to notify the registered nurse of the findings. The
registered nurse will then notify the health care provider for further prescriptions. Option 2 will
have little, if any, effect on peripheral edema and weight gain. Option 3 infers that a diuretic will
help the situation, and it is possible that the health care provider will prescribe a diuretic;
however, the health care provider needs to be aware of the change in the physical condition of
the client. The nurse should not increase or decrease the rate of parenteral nutrition infusions
without a health care provider's prescription to do so.
The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the
client is experiencing which heart rhythm? Refer to figure. - ANS Atrial fibrillation
Diagram of normal sinus rhythm as seen on ECG. In atrial fibrillation the P waves, which
represent depolarization of the top of the heart, are absent
The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy.
A wound drain is in place in the abdominal wound. Which nursing action would be appropriate
during the dressing change? - ANS Checking the wound site for drainage from the drain
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, Rationale:
The wound site needs to be checked for drainage from the drain; the drainage can excoriate the
skin. Usually the drainage from the wound is pale, red, and watery. Active bleeding is bright red.
Aseptic technique must be used when changing the dressing to avoid contamination of the
wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit
for the fluid and blood to promote healing. The drainage needs to flow freely, and there should
be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of drainage. The
tube is not advanced.
When caring for a client who is having clear drainage from his nares after transsphenoidal
hypophysectomy, which action by the nurse is essential? - ANS Test the drainage for glucose.
Rationale:
After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a
cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for
glucose, indicating the presence of CSF. The head of the bed should not be lowered to prevent
increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture.
Continuing to observe the drainage without taking action could result in a serious complication.
A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy.
Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement
protective isolation procedures. Which interventions should the nurse initiate? Select all that
apply. - ANS 1. Place the child on a low-bacteria diet.
2. Change dressings using sterile technique.
3. Perform meticulous hand washing before caring for the child.
Rationale:
For the hospitalized neutropenic child, flowers or plants should not be kept in the room because
standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are
very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should
be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet.
Dressings are always changed with sterile technique. Not all visitors need to be restricted, but
anyone who is ill should not be allowed in the child's room Meticulous hand washing is required
before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
