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NCLEX PRACTICE TEST 2026 FULL SOLUTION
VIEW AHEAD
▶ What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases? A) Requesting that a family member remain with the client to assist in ambulation B) Keeping all four siderails up while the client is in bed C) Placing the client in restraints to prevent movement without assistance D) Providing assistance to the client in getting out of the bed or chair. Answer: D Advanced age and multiple illnesses, particularly those that result in alterations in sensation, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to prevent falls. The client should not be restrained or maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point. ▶ The nurse is caring for four clients. Which client assessment is the most indicative of having pain? A) Client stating that he is "anxious" B) Heart rate of 105 beats/min and restlessness C) Blood pressure 150/70 mm Hg and sleeping D) Postoperative client with a neck incision. Answer: B At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.
▶ The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? A) Prescribe aspirin for a client who presents with an acute myocardial infarction B) Insert a central line to give intravenous fluid to a dehydrated client. C) Use sterile technique when changing dressings on a new surgical site. D) Intubate a client whose oxygen saturation is 92%.. Answer: C The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician. ▶ Which is most indicative of pain in an older client who is confused? (Select all that apply). A) Screaming B) Decreased blood pressure C) Crying D) Decreased respirations E) Facial grimace F) Restlessness. Answer: A,C,E,F No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations. ▶ The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is: A) large for gestational age. B) well nourished. C) born at term. D) low birth weight.. Answer: D Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for
and notifying the physician of a change in the client's status after a medication change would not be considered activities of the Rapid Response Team. ▶ An older client just returned from surgery and is rating pain as "8" on a 0 to 10 scale. Which medications are unsafe choices for treatment of severe pain in this older adult? (Select all that apply.) A) Morphine (Durmorph) B) Meperidine (Demerol) C) Propoxyphene (Darvocet) D) Methadone (Dolophine) E) Codeine. Answer: B,C,D,E Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the gold standard and may be used in the older adult while monitoring for sedation and respiratory depression is conducted. ▶ An emergency department (ED) nurse gives report on a client who is being transferred to the medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This statement represents which part of the SBAR hand- off? A) Situation B) Recommendation C) Background D) Assessment. Answer: B The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to start for the client who is being transferred. No communication is provided in the SBAR report about the situation, background, or assessment. ▶ Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining
tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of: A) mixed pain syndrome. B) chronic pain. C) neuropathic pain. D) nociceptive pain.. Answer: D Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. ▶ The new nurse is caring for a client with a high temperature. Which action should the nurse perform FIRST? A) Obtaining a fan from central supply for the client's room B) Monitoring the client's temperature more often than ordered C) Sponging the client while monitoring for shivering D) Apply cool packs to the client's axillae and groin. Answer: D The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate. ▶ A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? A) The patient will demonstrate coping skills needed to manage hypertension. B) The patient will verbalize the side effects of treatment. C) The patient will select the type of learning materials they prefer.
A) 8 mL B) 7.5 mL C) 7 mL D) 5.5 mL. Answer: B ▶ The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? A) KCl 20 mEq PO two times per day B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr C) Oxygen via face mask at 8 L/min D) Furosemide (Lasix) 20 mg PO now. Answer: B A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess. ▶ The priority nursing intervention for a patient suspected to be hypothermic would be to: A) hydrate with intravenous (IV) fluids. B) remove wet clothes. C) assess vital signs. D) provide a warm blanket.. Answer: B The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.
▶ The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates: A) slow capillary refill. B) red, sweaty skin. C) low pulse rate. D) decreased respirations.. Answer: B With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill. ▶ Why does the nurse always ask the client his or her pain level after taking routine vital signs? A) To follow McCaffery's guidelines on pain management B) To ensure that pain assessment occurs on a regular basis C) To determine the need for more frequent vital sign measurement D) To determine whether pain is influencing blood pressure and heart rate. Answer: B Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management. ▶ The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? A) Examine dependent body areas. B) Notify the physician. C) Document the finding and continue to monitor. D) Assess turgor on the client's forehead.. Answer: D Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is
Early signs and symptoms of MS include changes in motor skills, vision, and sensation. The other manifestations are later signs of MS. ▶ The nurse determines that a client has a Braden Scale score of 9. Which is the nurse's best intervention related to this assessment? A) Increase the client's fluid intake. B) Consult with the health care provider. C) Reassess the client in 3 days. D) Document the finding per protocol.. Answer: B A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer development in terms of decreased sensory perception, exposure to moisture, decreased independent activity, decreased mobility, poor nutrition, and chronic exposure to friction and shear. The nurse needs to consult with the health care provider to relay this information and to obtain more aggressive skin protection measures than are currently provided. ▶ While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? A) Completing all nursing care in the evening when the patient is more rested B) Completing all nursing care in the morning so the patient can rest the remainder of the day C) Limiting visitors, thus promoting the maximal amount of hours for sleep D) Prioritization and administration of nursing care throughout the day. Answer: D Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation. ▶ A diabetic client has numbness and reduced sensation. Which intervention does the nurse teach this client to prevent injury? A) "Use a bath thermometer to test the water temperature."
B) "Examine your feet daily using a mirror." C) "Wear white socks instead of colored socks." D) "Rotate your insulin injection sites.". Answer: A Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury. ▶ Which client does the nurse assess to be at greatest risk for pressure ulcer development? A) Client who requires assistance with ambulation B) Incontinent client with limited mobility C) Client with hypertension on multiple medications D) Client who has pneumonia. Answer: B Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. Clients with pneumonia and hypertension do not have specific risk factors. The client who needs assistance with ambulation might be at moderate risk if he or she does not move about much, but having two risk factors makes the last option the person at highest risk. ▶ The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to: A) bathe and dry the skin vigorously to stimulate circulation. B) limit intake of fluid and offer frequent snacks. C) turn the patient at least every 2 hours. D) keep the head of the bed elevated 30 degrees.. Answer: C The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because
To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility. ▶ The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment? A) Place the client in high Fowler's position. B) Verbalize the placement of food on the client's plate. C) Order a clear liquid diet for the client. D) Turn the client's plate around halfway through the meal.. Answer: A Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client's diet to clear liquids. ▶ Which statement indicates that the client needs more teaching about mucositis? A) "I will use a soft-bristled toothbrush to prevent trauma." B) "I will rinse my mouth with water after every meal." C) "I should use an alcohol-based mouth rinse to kill bacteria." D) "I cannot use floss because it may irritate my gums.". Answer: C Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation associated with mucositis. ▶ A young woman is being treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the highest priority instruction for the nurse to give this client?
A) "You may experience an irregular heartbeat while on the drug." B) "Watch for blood in your urine while taking this drug." C) "Use a second form of birth control while on the drug." D) "You will experience increased menstrual bleeding while on this drug.". Answer: C The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication. ▶ The nurse prepares to teach a patient recovering from a myocardial infarction (MI) about combination durg therapy based on "best practice" for controlling hypertension. Which drugs does the nurse include in the teaching plan? SELECT ALL THAT APPLY!!! A) NSAID's B) Aspirin C) Aldosterone antagonists D) ACE Inhibitors or ARB's E) Central alpha Agonists F) Beta Blockers G) Diuretics. Answer: B,C,D,F,G ▶ The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client? A) Turn on the television to a 24-hour news station. B) Provide auditory and visual stimulation simultaneously. C) Ask the family to bring in pictures familiar to the client. D) Maintain a calm and quite environment by minimizing visitors.. Answer: C For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion.
A) "Can we discontinue the in-dwelling catheter?" B) "Will the client be able to return home?" C) "Should we get another chest x-ray today?" D) "Do you want daily weights on this client?". Answer: A An in-dwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority. ▶ The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? A) Agraphia B) Aphasia C) Impaired olfaction D) Impaired proprioception. Answer: D A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write. ▶ A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action? A) Restrict fluid intake. B) Prevent ketosis. C) Control hyperglycemia. D) Prevent hypoglycemia.. Answer: C Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control. Restricting fluid intake is not part of the treatment plan for clients with diabetes.
▶ Which interventions are necessary to provide safe, quality care to a patient receiving enteral tube feedings? SELECT ALL THAT APPLY!! A) check the residual volume every 4-6 hours B) use clean technique when changing the feeding system C) keep the head of the beg elevated at least 30 degrees D) change the feeding bag & tubing every 12 hours E) allow closed system containers to hang for 24 hours. Answer: A,B,C,E ▶ A client with a pressure ulcer has the following laboratory values: white blood count 8000/mm3, prealbumin 15.2 mg/dL, albumin 4.2 mg/dL, and lymphocyte count 2000/mm3. Which action by the nurse is most appropriate? A) Request a dietary consult. B) Assess the client's vital signs. C) Document the findings. D) Place the client in isolation.. Answer: A Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The albumin and lymphocyte counts given are normal. The white blood cell count is not directly related to nutritional status. The prealbumin count is low and is a more specific indicator of nutritional status than is the albumin count. This puts the client at risk for impaired wound healing, so the nurse should request a dietary consult. ▶ A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, "Perfusion A) is a normal function of the body, and I don't have to be concerned about it." B) varies as a person ages, so I would expect changes in the body." C) is monitored by the physician, and I just follow orders." D) is monitored by vital signs and capillary refill.". Answer: D The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is
A) Auscultate bowel sounds and slow the feeding down. B) Remove the tube immediately and notify the heath care provider. C) Auscultate lung sounds and obtain oxygen saturation. D) Add blue dye to the feeding tube formula.. Answer: C The client may have aspirated. The nurse should further assess the client's respiratory and oxygenation status. The client may have another reason for the abnormal vital signs, so the nurse should not pull out the tube before performing other assessments. Adding blue dye to the tube feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be helpful. ▶ A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse's first action when the client reports burning at the site? A) Apply a cold compress. B) Discontinue the infusion. C) Slow the rate of infusion. D) Check for a blood return.. Answer: B Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she should immediately stop the infusion. Even if the IV has a good blood return, some of the chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the correct action, depending on the specific agent. However, the compress would be applied only after the infusion has been discontinued. ▶ which statement about a patient with a tube feeding indicates best practice for patient safety & quality care? A) if the tube becomes clogged, use 30 mL of water for flushing, while applying gentle pressure with a 50 mL piston syringe B) when administering medications, use cold water to dissolve the drug before administering it C) use cranberry juice to flush the tube if it is clogged
D) administer drugs down the feeding tube without flushing first, but flush the feeding tube after the drug is given. Answer: A ▶ A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action? A) Document as a stage I pressure ulcer and apply a transparent dressing. B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments. C) Document as a stage IV pressure ulcer and prepare the client for débridement. D) Document as a stage III pressure ulcer and start antibiotic therapy.. Answer: C A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of débridement of the necrotic tissue and a possible graft to promote healing. ▶ After initial placement of NG tubes is confirmed, how often must placement be checked? SELECT ALL THAT APPLY? A) before medication administration B) it is not necessary to recheck placement C) every 4-8 hours during feeding D) before intermittent feeding E) according to facility policy. Answer: A,C,E ▶ The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse? A) Start the tube feeding as ordered and check the residual in 30 minutes. B) Inject air into the nasogastric tube while auscultating the client's epigastric area. C) Lower the head of the client's bed and attempt to aspirate fluid again.
