NCLEX-PN Nursing — All Questions

A client with depression states, "I feel like a burden to everyone." Which response is most therapeutic?

• a."You shouldn't feel that way; everyone loves you."
• b."Tell me more about how you have been feeling."✓
• c."At least you have a supportive family."
• d."Let's talk about something more pleasant."

Encouraging the client to say more invites expression of feelings and conveys genuine interest. Minimizing feelings, changing the subject, and comparing to others block communication. Open-ended exploration is therapeutic.

A client with dementia becomes agitated in the evening. Which intervention is most appropriate?

• a.Frequently change caregivers to provide stimulation
• b.Increase environmental noise and activity
• c.Provide a calm, well-lit environment and a consistent routine✓
• d.Restrain the client to prevent wandering

A calm, well-lit environment with consistent routines and caregivers reduces evening agitation, sometimes called sundowning. Excess stimulation, restraints, and frequent caregiver changes worsen confusion. Predictability promotes security.

A client who has been assaulted appears withdrawn and avoids eye contact. What is the nurse's best initial approach?

• a.Provide a safe, private environment and allow the client to talk when ready✓
• b.Insist that the client describe the assault in detail before any other care
• c.Discuss the incident in the hallway within earshot of other clients
• d.Tell the client to move past the experience and focus on going home

Providing safety, privacy, and unhurried support helps a trauma survivor feel secure and regain a sense of control. Forcing disclosure or minimizing feelings is harmful. The nurse follows the client's pace.

Which behavior indicates a client may be at immediate risk for suicide and requires priority intervention?

• a.Attending group therapy sessions each morning
• b.Expressing hope about plans after discharge
• c.Giving away personal possessions and stating goodbyes✓
• d.Discussing new coping strategies with the nurse

Giving away belongings and saying goodbye can signal a suicide plan and requires immediate assessment and safety measures. Hopeful statements and engagement in therapy are positive signs. Direct assessment of suicidal intent is essential.

A client from a culture that values family decision-making asks that all information be shared with the family. What is the nurse's best response?

• a.Refuse the request because sharing anything with family violates confidentiality
• b.Respect the client's wishes and involve the family as the client directs✓
• c.Insist that only the client receive information about the diagnosis
• d.Share the information with the client's employer instead of the family

Culturally sensitive care respects the client's preferences about who participates in decisions. When a competent client authorizes family involvement, the nurse honors that choice. Individual and cultural values guide communication.

A client experiencing alcohol withdrawal is anxious and tremulous. Which environment is most appropriate?

• a.A brightly lit, busy room to keep the client engaged and awake
• b.A dark, isolated room checked once at the end of the shift
• c.A quiet room with reduced stimulation and frequent monitoring✓
• d.A shared room with several visitors coming and going

A quiet, low-stimulation environment with close monitoring helps reduce agitation and detects worsening withdrawal. Excess stimulation can heighten anxiety, and isolation without supervision is unsafe. Safety and calm are priorities.

A client verbalizes anger at the nursing staff about the diagnosis. Which response by the nurse is most therapeutic?

• a."You have no reason to be angry with the nursing staff."
• b."You seem upset. Can you tell me what is troubling you?"✓
• c."If you keep yelling at me, I will leave the room."
• d."Calm down and stop being difficult with the staff."

Acknowledging the client's feelings and inviting them to talk helps identify the underlying concern. Defensive or dismissive responses escalate anger and block communication. Reflecting emotion is a therapeutic technique.

Which coping strategy is considered adaptive for a client experiencing situational stress?

• a.Denying that any problem exists until the stress passes
• b.Talking with a trusted friend and using relaxation techniques✓
• c.Withdrawing from all social contact until the situation resolves
• d.Using alcohol each evening to relax and fall asleep faster

Seeking social support and using relaxation are healthy, adaptive coping strategies. Alcohol use, social withdrawal, and denial are maladaptive and can worsen stress. Reinforcing positive coping supports mental health.

A client with a new colostomy states, "I don't want to look at it. It's disgusting." What is the nurse's best response?

• a."Let's not discuss the stoma at all until you are feeling better."
• b."Most people adjust to a colostomy very quickly, so there is really no need to worry."
• c."You will have to look at it eventually, so you may as well get it over with now."
• d."It is normal to have these feelings after surgery. Would you like to talk about it?"✓

Acknowledging feelings about an altered body image and inviting discussion supports adjustment. Pressuring the client or minimizing feelings is nontherapeutic. Emotional support precedes self-care teaching.

A confused older adult repeatedly asks to go home. Which nursing response is most therapeutic?

• a."You cannot go home, so please stop asking me about it."
• b."Your family left you here and they are not coming back for you."
• c."You seem worried. You are safe here, and I will stay with you."✓
• d."I have already answered that same question three times today."

Providing reassurance, orientation, and a calm presence reduces anxiety in a confused client. Harsh or dismissive replies increase distress. Validating feelings and offering comfort are therapeutic.

The LPN/LVN is collecting data on a client with heart failure. Which finding should be reported to the RN promptly?

• a.Clear lung sounds bilaterally
• b.Sudden weight gain of 3 pounds overnight✓
• c.Heart rate of 76 beats per minute
• d.Blood pressure of 122/78 mmHg

A sudden weight gain suggests fluid retention and worsening heart failure and should be reported. Normal blood pressure, clear lungs, and a normal heart rate are reassuring. Daily weights are a key monitoring tool in heart failure.

A client with diabetes reports shakiness, sweating, and dizziness. The blood glucose is 55 mg/dL. What should the LPN/LVN do first?

• a.Encourage the client to rest until symptoms pass
• b.Withhold all food and recheck in one hour
• c.Give 15 grams of a fast-acting carbohydrate✓
• d.Administer the client's evening insulin dose

Symptoms and a glucose of 55 mg/dL indicate hypoglycemia, treated with 15 grams of fast-acting carbohydrate and rechecking in 15 minutes. Giving insulin would worsen hypoglycemia. Prompt treatment prevents progression to severe hypoglycemia.

The LPN/LVN is caring for a client after a total hip replacement. Which position should be maintained to prevent dislocation?

• a.Legs abducted with a wedge pillow between the knees✓
• b.Turned fully onto the operative side to relieve pressure
• c.Legs crossed at the ankles with the knees held together
• d.Hip flexed greater than 90 degrees while sitting upright

Keeping the legs abducted with a wedge pillow prevents adduction and dislocation of the new hip. Crossing the legs, flexing the hip beyond 90 degrees, and lying on the operative side are contraindicated. Positioning protects the prosthesis.

A client with chronic obstructive pulmonary disease has an oxygen order. Which oxygen flow is generally most appropriate?

• a.15 L/min by nonrebreather
• b.10 L/min by simple mask
• c.8 L/min by nasal cannula
• d.2 L/min by nasal cannula✓

Clients with COPD typically receive low-flow oxygen, such as 2 L/min, to maintain adequate oxygenation without suppressing respiratory drive. High flow rates may be used only in emergencies with close monitoring. Titrating to target saturation is important.

The LPN/LVN is monitoring a client receiving a blood transfusion. Which finding suggests a transfusion reaction and requires stopping the infusion?

• a.Temperature unchanged from the pretransfusion baseline value
• b.Report of feeling comfortable and warm under the blankets
• c.Blood pressure of 120/70 mmHg, unchanged from baseline
• d.Fever, chills, and flank pain shortly after the start✓

Fever, chills, and flank pain suggest a hemolytic transfusion reaction; the transfusion must be stopped and the RN notified immediately. Stable vital signs and comfort are reassuring. Early recognition prevents serious harm.

A client is admitted with dehydration. Which finding supports this diagnosis?

• a.Crackles heard throughout both lung fields
• b.Bounding pulses and pitting edema of the ankles
• c.Dry mucous membranes and poor skin turgor✓
• d.Distended neck veins while sitting upright

Dry mucous membranes and poor skin turgor are classic signs of fluid volume deficit. Bounding pulses, edema, crackles, and distended neck veins indicate fluid overload. Assessing hydration status guides fluid therapy.

The LPN/LVN is caring for a client with a nasogastric tube for decompression. Which finding requires prompt attention?

• a.The client reports nausea and the tube has stopped draining✓
• b.A small amount of greenish drainage in the suction canister
• c.The client's mouth and lips are moist following routine oral care
• d.The tube is connected to low intermittent suction as ordered

If drainage stops and the client is nauseated, the tube may be clogged or malpositioned and requires prompt evaluation. Green drainage and connection to suction are expected. Maintaining patency relieves gastric distention.

A client with a new colostomy has a stoma that is dark purple. What does this finding indicate?

• a.Expected bruising from surgery that will fade on its own
• b.Possible impaired circulation that must be reported✓
• c.A sign of an unusually rich blood supply to the stoma
• d.The normal color of a healthy, well-healed stoma

A healthy stoma is pink or red and moist; a dark purple or black stoma suggests compromised blood supply and must be reported immediately. Impaired circulation can lead to necrosis. Prompt reporting allows early intervention.

The LPN/LVN is caring for a client with a cast on the right lower leg. Which finding indicates possible compartment syndrome?

• a.Severe pain unrelieved by medication and numbness of the toes✓
• b.The cast feels dry and firm to the touch several hours later
• c.Pink, warm toes with brisk capillary refill below the cast edge
• d.Mild itching of the skin beneath the upper edge of the cast

Unrelieved severe pain and numbness are warning signs of compartment syndrome, a limb-threatening emergency. Pink, warm toes with brisk capillary refill are normal findings. Neurovascular changes must be reported immediately.

A client is 1 day postoperative after abdominal surgery. Which intervention best prevents postoperative pneumonia?

• a.Limit fluid intake to reduce the amount of secretions in the lungs
• b.Keep the client on strict bed rest until the incision is fully healed
• c.Withhold pain medication so the client stays alert enough to breathe
• d.Encourage use of an incentive spirometer and coughing and deep breathing✓

Incentive spirometry with coughing and deep breathing expands the lungs and clears secretions, preventing atelectasis and pneumonia. Immobility and unrelieved pain reduce lung expansion. Adequate hydration keeps secretions thin.

The LPN/LVN collects data on a client with hypothyroidism. Which finding is consistent with this condition?

• a.Fatigue, cold intolerance, and constipation✓
• b.Weight loss, heat intolerance, and difficulty sleeping
• c.Restlessness, fine hand tremors, and anxiety
• d.Tachycardia, diarrhea, and warm moist skin

Hypothyroidism slows metabolism, causing fatigue, cold intolerance, and constipation. Weight loss, heat intolerance, tachycardia, and tremors indicate hyperthyroidism. Recognizing the pattern guides monitoring.

A client with a pressure injury has a wound with visible subcutaneous fat but no muscle or bone. How is this best described?

• a.Deep tissue injury
• b.Stage 3 pressure injury✓
• c.Stage 2 pressure injury
• d.Stage 1 pressure injury

A stage 3 pressure injury involves full-thickness skin loss with visible subcutaneous fat but no exposed muscle or bone. Stage 1 has intact skin, and stage 2 involves partial-thickness loss. Accurate staging guides treatment.

The LPN/LVN is caring for a client with a seizure history who is NPO for a procedure. Which action is most appropriate regarding antiseizure medication?

• a.Give the medication with a large glass of water despite the NPO order
• b.Double the next dose after the procedure to make up for the missed one
• c.Automatically hold all of the client's medications because the order is NPO
• d.Clarify with the RN or provider whether the medication should still be given✓

Antiseizure medications are often continued even when a client is NPO, so the nurse should clarify orders rather than automatically holding them. Withholding may precipitate seizures. Doubling doses is unsafe.

A client with cirrhosis has ascites. Which position best promotes comfort and breathing?

• a.Prone position with the abdomen down
• b.Flat supine position with one pillow
• c.Semi-Fowler's or Fowler's position✓
• d.Trendelenburg, head-down position

Elevating the head of the bed to a semi-Fowler's or Fowler's position eases breathing by reducing pressure of ascitic fluid on the diaphragm. Flat, head-down, and prone positions increase respiratory effort. Positioning improves ventilation.

The LPN/LVN reviews intake and output for a client with an indwelling catheter. Urine output has been less than 30 mL/hour for several hours. What should the nurse do?

• a.Clamp the catheter for two hours
• b.Increase the client's activity level
• c.Report the decreased output to the RN✓
• d.Document as a normal finding

Urine output persistently below 30 mL/hour may indicate impaired kidney perfusion or obstruction and should be reported. It is not a normal finding to document without action. Timely reporting supports early intervention.

A client recovering from a stroke has difficulty swallowing. Which intervention best reduces the risk of aspiration during meals?

• a.Offer thin liquids through a straw so meals can be finished quickly
• b.Encourage rapid eating so meals are finished before fatigue sets in
• c.Position the client upright and provide thickened liquids as ordered✓
• d.Have the client lie flat during meals to relax the throat muscles

Sitting upright and using thickened liquids as ordered reduces aspiration risk in clients with dysphagia. Lying flat, thin liquids, and rapid eating increase risk. Safe swallowing precautions protect the airway.

The LPN/LVN is caring for a client with a peripheral IV. The site is red, warm, and tender. What is the priority action?

• a.Stop the infusion and remove the IV catheter✓
• b.Increase the infusion rate to flush the vein
• c.Document and reassess at the end of the shift
• d.Apply a warm compress and continue the infusion

Redness, warmth, and tenderness indicate phlebitis; the infusion should be stopped and the catheter removed to prevent complications. Increasing the rate or continuing infusion worsens the problem. The site is then restarted elsewhere as needed.

A client with pneumonia has an oxygen saturation of 88% on room air. Which action should the LPN/LVN take first?

• a.Withhold oxygen until the provider rounds later in the day
• b.Offer a cold beverage and recheck the reading in an hour
• c.Apply oxygen as ordered and reposition to high Fowler's✓
• d.Encourage the client to lie flat to rest the breathing muscles

An oxygen saturation of 88% indicates hypoxemia; applying oxygen as ordered and positioning upright improves oxygenation. Lying flat and withholding oxygen worsen the problem. Prompt oxygenation is the priority.

The LPN/LVN is monitoring a client after a thyroidectomy. Which finding requires immediate attention?

• a.Sore throat when swallowing on the first day
• b.Small amount of drainage on the neck dressing
• c.Hoarse voice for a few hours after surgery
• d.Tingling around the mouth and muscle twitching✓

Tingling around the mouth and muscle twitching suggest hypocalcemia from inadvertent parathyroid injury, a serious complication after thyroidectomy. A sore throat, temporary hoarseness, and minimal drainage are expected. Calcium changes require prompt reporting.

A client with a fractured femur suddenly develops shortness of breath, chest pain, and confusion. What complication should the nurse suspect?

• a.Urinary retention from bed rest
• b.Constipation from immobility
• c.Fat or pulmonary embolism✓
• d.Mild situational anxiety

Sudden dyspnea, chest pain, and confusion after a long-bone fracture may indicate a fat or pulmonary embolism, a medical emergency. These symptoms are not explained by constipation or urinary retention. Rapid recognition and response are critical.

The LPN/LVN is reinforcing teaching to a client with a new diagnosis of gastroesophageal reflux disease. Which instruction is appropriate?

• a.Avoid lying down for 2 to 3 hours after eating✓
• b.Increase caffeine and fatty foods
• c.Eat large meals late in the evening
• d.Lie flat immediately after meals

Remaining upright for several hours after meals reduces reflux. Large late meals, lying flat after eating, and caffeine and fatty foods worsen symptoms. Lifestyle changes are first-line management.

A client is receiving continuous enteral tube feeding. To reduce the risk of aspiration, the head of the bed should be maintained at what minimum elevation?

• a.Prone position
• b.Flat at 0 degrees
• c.At least 30 degrees✓
• d.No more than 10 degrees

Keeping the head of the bed elevated at least 30 degrees during enteral feeding reduces the risk of aspiration. A flat position increases reflux and aspiration risk. Elevation is a key safety measure.

The LPN/LVN collects data on a client with appendicitis. Which finding is most consistent with this condition?

• a.Painless bright red rectal bleeding noted with stools
• b.Left upper quadrant burning an hour after meals
• c.Pain that is fully relieved by eating a meal
• d.Right lower quadrant pain with rebound tenderness✓

Appendicitis classically causes right lower quadrant pain with rebound tenderness. Pain relieved by eating and left upper quadrant burning suggest other conditions. Recognizing the pattern supports timely care.

A client with anemia has a hemoglobin of 7 g/dL and reports fatigue and dizziness on standing. Which intervention is a priority?

• a.Encourage vigorous exercise to raise the hemoglobin faster
• b.Ambulate the client rapidly and without assistance to build stamina
• c.Assist with slow position changes and monitor for dizziness✓
• d.Restrict all fluids so that the blood becomes more concentrated

Low hemoglobin reduces oxygen delivery, causing fatigue and orthostatic symptoms; assisting with slow position changes prevents falls. Vigorous exercise and rapid independent ambulation are unsafe. Safety and energy conservation are priorities.

The LPN/LVN is caring for a client with a chest tube. The nurse notes continuous bubbling in the water-seal chamber. What is the appropriate action?

• a.Strip the tubing vigorously and continuously until the bubbling stops
• b.Check the tubing and connections for an air leak and notify the RN✓
• c.Raise the drainage system above the level of the client's chest
• d.Clamp the chest tube for the rest of the shift and recheck later

Continuous bubbling in the water-seal chamber may indicate an air leak in the system that should be investigated and reported. Clamping a chest tube can cause a tension pneumothorax. The system is kept below the chest.

A client reports burning on urination, urinary frequency, and lower abdominal discomfort. Which condition is most likely?

• a.Urinary tract infection✓
• b.Obstructing kidney stone
• c.Acute gallbladder disease
• d.Early acute appendicitis

Burning on urination, frequency, and suprapubic discomfort are classic signs of a urinary tract infection. These symptoms differ from appendicitis or gallbladder disease. Collecting a urine specimen supports diagnosis.

The LPN/LVN is caring for a client after a mastectomy. Which action helps prevent lymphedema in the affected arm?

• a.Avoid blood pressure measurement and venipuncture on the affected arm✓
• b.Draw blood samples from the affected arm to spare the other side
• c.Keep the affected arm dependent below heart level so that fluid drains
• d.Take blood pressure readings on the affected arm at every check

Avoiding blood pressure measurement and venipuncture on the affected arm helps prevent lymphedema after mastectomy. The arm is also elevated, not kept dependent, to promote lymph drainage. Protecting the arm reduces swelling and infection risk.

A client with diabetes has a foot ulcer. Which teaching point best supports healing and prevents further injury?

• a.Trim calluses at home with a razor blade after bathing
• b.Soak the feet in hot water every day to soften them
• c.Inspect the feet daily and wear well-fitting shoes✓
• d.Walk barefoot at home so the ulcer stays uncovered

Daily foot inspection and well-fitting footwear prevent unnoticed injury and support healing in clients with diabetes. Walking barefoot, hot soaks, and self-trimming calluses increase the risk of injury and infection. Foot care is essential in diabetes.

The LPN/LVN is collecting data on a client who had a stroke affecting the left side of the brain. Which deficit is most likely?

• a.Left-sided weakness with no change in speech
• b.Right-sided weakness and difficulty with speech✓
• c.Inability to hear in both ears with normal strength
• d.Complete loss of vision in both eyes with no weakness

A stroke on the left side of the brain typically causes right-sided weakness and often affects speech because language centers are usually on the left. Left-sided weakness suggests a right-brain stroke. Recognizing deficits guides rehabilitation.

A client with heart failure is prescribed a low-sodium diet. Which food selection indicates understanding of the diet?

• a.Fresh vegetables and grilled chicken✓
• b.Processed lunch meat sandwiches
• c.Canned soup and cured ham
• d.Salted nuts and pickles

Fresh vegetables and unprocessed grilled chicken are low in sodium and appropriate for heart failure. Canned soup, cured meats, salted nuts, and processed meats are high in sodium. Limiting sodium helps control fluid retention.

The LPN/LVN is caring for an immobile client. Which intervention best prevents pressure injuries?

• a.Reposition the client at least every 2 hours✓
• b.Massage reddened bony prominences vigorously
• c.Use a doughnut-shaped cushion under the sacrum
• d.Keep the head of the bed elevated to 90 degrees continuously

Repositioning at least every 2 hours relieves pressure and prevents skin breakdown. Vigorous massage of reddened areas and doughnut cushions can worsen tissue damage. Frequent turning and skin care are key preventive measures.

The LPN/LVN is caring for a client with acute pancreatitis. Which measure is a priority in the acute phase?

• a.Position the client flat on the back to relax the abdomen
• b.Maintain NPO status to rest the pancreas as ordered✓
• c.Encourage a high-fat diet to keep up calorie intake
• d.Provide frequent large meals throughout the day

Keeping the client NPO reduces pancreatic stimulation and rests the inflamed organ during the acute phase. High-fat and large meals stimulate enzyme secretion and worsen pain. Pain control and monitoring are also priorities.

Before administering digoxin, the LPN/LVN should assess which parameter?

• a.The client's temperature
• b.Apical heart rate for a full minute✓
• c.The client's respiratory rate only
• d.The client's blood glucose

Digoxin can slow the heart rate, so the apical pulse should be counted for a full minute before administration. If the rate is below 60 beats per minute in an adult, the dose is typically held and the provider notified. This check prevents bradycardia-related harm.

A client is prescribed warfarin. Which laboratory test is used to monitor its therapeutic effect?

• a.Total white cell count
• b.Fasting blood glucose level
• c.Prothrombin time and INR✓
• d.Serum potassium level

Warfarin's anticoagulant effect is monitored with the prothrombin time and international normalized ratio (INR). Glucose, potassium, and white cell counts are not used to adjust warfarin. Monitoring the INR prevents bleeding and clotting.

The LPN/LVN is administering an oral iron supplement. Which instruction improves absorption?

• a.Take iron right after a large meal, since a full stomach speeds uptake
• b.Take iron with a large glass of milk to improve absorption
• c.Take iron together with an antacid to improve absorption
• d.Take iron with a source of vitamin C such as orange juice✓

Vitamin C enhances the absorption of oral iron, so taking it with orange juice is helpful. Milk and antacids reduce absorption. Iron may be taken with food to reduce stomach upset if needed, but vitamin C aids uptake.

A client is receiving furosemide, a loop diuretic. Which electrolyte imbalance should the LPN/LVN monitor for?

• a.Hyperkalemia
• b.Hypercalcemia
• c.Hypokalemia✓
• d.Hypernatremia

Loop diuretics like furosemide increase potassium excretion and can cause hypokalemia. Signs include muscle weakness and cardiac dysrhythmias. Monitoring potassium and encouraging potassium-rich foods may be indicated.

The LPN/LVN is preparing to give an intramuscular injection to an adult in the ventrogluteal site. Why is this site preferred?

• a.It is approved only for infants and small children
• b.It is closest to the sciatic nerve and needs no landmarks
• c.It is away from major nerves and blood vessels✓
• d.It has the least muscle mass of any injection site

The ventrogluteal site is preferred for many intramuscular injections because it is away from major nerves and blood vessels and has adequate muscle mass. The dorsogluteal site poses more risk to the sciatic nerve. Correct site selection improves safety.

A client is prescribed an oral tetracycline antibiotic. Which instruction is appropriate?

• a.Avoid dairy products and antacids around the time of the dose✓
• b.Take it with dairy products such as milk to improve absorption
• c.Take it only at bedtime with a glass of milk and an antacid
• d.Double the next dose whenever a meal has been missed

Tetracyclines bind with calcium in dairy and with antacids, reducing absorption, so these should be separated from the dose. Doubling doses is unsafe. Proper timing ensures effectiveness.

The LPN/LVN is administering insulin. Which action is correct when giving regular and NPH insulin together in one syringe?

• a.Shake both vials vigorously before drawing up either insulin
• b.Never mix regular and NPH insulin, because the two inactivate each other
• c.Draw up the NPH (cloudy) insulin before the regular (clear) insulin
• d.Draw up the regular (clear) insulin before the NPH (cloudy) insulin✓

When mixing insulins, the regular (clear) insulin is drawn up before the NPH (cloudy) insulin to avoid contaminating the clear vial. Vials are gently rolled, not shaken. Correct technique maintains accurate dosing.

A client taking an angiotensin-converting enzyme (ACE) inhibitor develops a persistent dry cough. What is the appropriate action?

• a.Report the cough to the RN or provider✓
• b.Stop all medications immediately without notification
• c.Increase the dose to relieve the cough
• d.Tell the client the cough is unrelated

A persistent dry cough is a known side effect of ACE inhibitors and should be reported so the provider can consider an alternative. Increasing the dose worsens the effect, and abruptly stopping without guidance is unsafe. Reporting supports appropriate management.