NCLEX-PN Nursing — All Questions

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.

An immobile client is at risk for pressure injury. Which action does the nurse take?

• a.Vigorously massage any reddened areas
• b.Reposition the client at least every 2 hours✓
• c.Keep the head of the bed elevated at all times
• d.Limit repositioning to reduce the client's discomfort

Reposition an immobile client at least every 2 hours to relieve pressure. Vigorous massage of reddened skin worsens tissue injury, constant head-of-bed elevation increases sacral shear, and limiting repositioning raises pressure-injury risk.

A client's urine output has been 25 mL/hr for three hours. The nurse should:

• a.Report the finding as it may indicate poor perfusion✓
• b.Clamp the catheter for one hour and reassess
• c.Document it as an expected postoperative finding
• d.Encourage the client to drink more water and continue monitoring

Urine output persistently below 30 mL/hr may indicate poor perfusion or obstruction and should be reported. Simply encouraging fluids or charting the output as expected delays care, and clamping the catheter is unsafe.

A conscious client with diabetes is diaphoretic and confused; a fingerstick reads 54 mg/dL. The nurse should:

• a.Give 15 g of fast-acting carbohydrate, wait 15 minutes, and recheck✓
• b.Withhold all food and fluids until the provider can be notified
• c.Administer the next scheduled dose of insulin as ordered
• d.Notify the provider, then wait for orders before giving anything by mouth

For symptomatic hypoglycemia in a conscious client, apply the 15-15 rule: 15 g of fast-acting carbohydrate, wait 15 minutes, recheck. Insulin would drive the glucose lower still; waiting for orders or withholding food delays needed treatment.

Fifteen minutes into a blood transfusion, a client develops chills, fever, and low-back pain. The nurse's first action is to:

• a.Stop the transfusion and keep the line open with normal saline✓
• b.Give an antipyretic and continue the transfusion at the prescribed rate
• c.Slow the infusion rate and continue the transfusion as ordered
• d.Increase the rate so the unit finishes before symptoms worsen

Signs of an acute transfusion reaction require you to stop the transfusion immediately and keep the line open with normal saline, then notify the RN. Slowing the rate, medicating and continuing, or speeding up all keep incompatible blood flowing.

A client with dysphagia is eating lunch. Which action prevents aspiration?

• a.Have the client lie flat so the muscles of the throat can relax
• b.Position the client upright and provide thickened liquids as ordered✓
• c.Offer plenty of thin liquids to help wash the food down quickly
• d.Encourage large bites so the client can finish the meal while it is hot

For dysphagia, position the client upright and provide thickened liquids as ordered to prevent aspiration. Thin liquids, lying flat, and large hurried bites all increase aspiration risk.

A client is receiving a tube feeding. To reduce aspiration risk, the nurse keeps the head of the bed at least:

• a.Flat (0 degrees)
• b.90 degrees at all times, even during sleep
• c.About 10 degrees
• d.30 degrees✓

Keep the head of the bed at least 30 degrees during and after tube feeding to reduce aspiration. Flat or barely raised positions increase the risk, and a rigid 90 degrees at all times is neither required nor practical for sleep.

A client 6 hours after a total hip replacement needs positioning. The nurse should:

• a.Elevate both knees sharply on pillows
• b.Turn the client fully onto the operative side
• c.Keep the legs abducted with a pillow between them✓
• d.Cross the client's legs at the ankles for comfort

After a total hip replacement, keep the legs abducted with a pillow between them to prevent dislocation. Crossing the legs, turning onto the operative side, and sharp flexion all risk dislocation.

A client with COPD is short of breath. Which oxygen approach is appropriate?

• a.High-flow oxygen at 10 L/min by simple face mask
• b.Low-flow oxygen, for example 2 L/min, targeting about 88–92%✓
• c.A nonrebreather mask at 15 L/min for routine use
• d.No supplemental oxygen, to preserve the client's hypoxic respiratory drive

In COPD, use low-flow oxygen (for example 2 L/min) targeting about 88–92%. High-flow delivery can blunt the hypoxic respiratory drive, and withholding oxygen from a hypoxic client is unsafe. *(Confirm the target with provider orders.)*

After a thyroidectomy, a client reports tingling around the mouth and muscle twitching. The nurse recognizes this as a sign of:

• a.Hyperkalemia
• b.Normal anesthesia after-effects
• c.Expected postoperative numbness that needs no action
• d.Hypocalcemia that should be reported promptly✓

Perioral tingling and muscle twitching after thyroidectomy indicate hypocalcemia (parathyroid involvement) and should be reported promptly. These findings are not benign postoperative numbness or anesthesia after-effects, and the electrolyte involved is calcium, not potassium.

Which finding in a client with heart failure should the nurse report promptly?

• a.A single episode of mild fatigue after the afternoon walk
• b.A weight gain of 3 pounds since yesterday with new crackles✓
• c.A blood pressure of 118/72 mmHg on the morning check
• d.Clear breath sounds and no edema on the evening data collection

A 3-pound weight gain with new crackles signals fluid overload in heart failure and must be reported promptly. Mild fatigue, a normal blood pressure, and clear lungs without edema are not urgent.

A client recovering from surgery is at risk for atelectasis and pneumonia. Which intervention does the nurse reinforce?

• a.Shallow breathing to protect the incision
• b.Withholding fluids to reduce secretions
• c.Strict bed rest with minimal movement
• d.Incentive spirometry, coughing, and deep breathing✓

Incentive spirometry, coughing, and deep breathing (with early ambulation) prevent atelectasis and pneumonia. Strict bed rest, withheld fluids, and shallow breathing increase the risk.

A client with a chest tube has continuous bubbling in the water-seal chamber. The nurse recognizes this as:

• a.Expected and requiring no action
• b.A reason to clamp the tube immediately
• c.A possible air leak that should be reported✓
• d.An indication to disconnect and flush the tubing

Continuous bubbling in the water-seal chamber suggests an air leak and should be reported. It is not an expected finding, and clamping or disconnecting the tube can cause a tension pneumothorax.

An LPN/VN is preparing to give a bolus feeding through a nasogastric tube. How should the client be positioned?

• a.With the head of the bed raised 30 to 45 degrees✓
• b.Flat on the back with the head turned to one side
• c.Sitting upright with the neck flexed toward the chest
• d.On the left side with the head of the bed lowered

Elevating the head of the bed 30 to 45 degrees during and after a feeding reduces reflux and aspiration. Supine positioning and Trendelenburg increase reflux, and neck flexion narrows the airway.

A client with a newly inserted nasogastric tube is about to receive the first feeding. What confirms correct tube placement?

• a.A radiograph read after the tube was inserted✓
• b.Air injected while listening over the epigastrium
• c.Aspirate with a pH of 5.5 from the tube
• d.Absence of coughing when the client swallows water

Radiographic confirmation is the standard before the first use of a blindly inserted feeding tube. A pH of 5.5 is not clearly gastric, the auscultatory air method is unreliable, and absence of coughing does not exclude a tube in the airway.

An LPN/VN is repositioning a client who is on bed rest. How should the client be turned to reduce pressure on the trochanter?

• a.To a 90-degree side-lying position on the hip
• b.To a 30-degree side-lying position✓
• c.To a prone position with the arms above the head
• d.To a fully supine position with the knees flexed

A 30-degree lateral tilt keeps weight off the greater trochanter. Lying directly on the hip concentrates pressure there, supine loading shifts pressure to the sacrum and heels, and prone positioning is not tolerated by most clients.

An LPN/VN observes a reddened area over a client's sacrum that does not turn white when pressed. How should this be described?

• a.Intact skin with nonblanchable redness of the area✓
• b.Partial-thickness skin loss with a shallow open base
• c.Skin loss covered by adherent yellow slough tissue
• d.Full-thickness skin loss with visible subcutaneous fat

Nonblanchable erythema over intact skin is the earliest recognizable pressure injury. Partial-thickness loss, visible fat, and slough-covered loss all describe deeper or obscured injuries.

An LPN/VN is providing care for a client with a stage 2 pressure injury on the heel. Which action is appropriate?

• a.Position the client on that heel for short periods
• b.Massage the reddened skin around the injury
• c.Apply a heat lamp to the area twice each day
• d.Keep the heel elevated off the surface of the bed✓

Offloading the heel removes the pressure that caused the injury. Massage over a compromised area causes further tissue damage, heat lamps dry and burn fragile skin, and any weight bearing continues the injury.

A client who had a stroke has difficulty swallowing. What should the LPN/VN do during meals?

• a.Place food on the weaker side of the client's mouth
• b.Offer thin liquids through a straw between the bites
• c.Seat the client upright and have the chin tucked down✓
• d.Seat the client upright and have the chin lifted up

An upright position with a chin tuck narrows the airway entrance and directs food toward the esophagus. Chin lift opens the airway to food, thin liquids through a straw move fastest and are hardest to control, and the weaker side pockets food.