NCLEX-PN Nursing — All Questions

An LPN/VN finds an unresponsive adult client with no normal breathing and no pulse. At what rate should chest compressions be delivered?

• a.80 to 100 compressions each minute
• b.100 to 120 compressions each minute✓
• c.130 to 150 compressions each minute
• d.60 to 80 compressions each minute

Current resuscitation guidelines specify a compression rate of 100 to 120 per minute for adults. Slower rates deliver inadequate perfusion, and rates above 120 shorten filling time between compressions.

An LPN/VN is performing chest compressions on an adult during a cardiac arrest. How deep should each compression be?

• a.At least 2 inches, about 5 centimeters✓
• b.At least half the depth of the chest wall
• c.At least 1 inch, about 2.5 centimeters
• d.At least 3 inches, about 7.5 centimeters

Adult compressions are at least 2 inches deep and not more than about 2.4 inches. One inch is too shallow to generate flow, 3 inches exceeds the safe range, and half the chest depth is the pediatric guideline of about one third.

An LPN/VN is giving CPR alone to an adult before a defibrillator arrives. What compression to ventilation ratio should be used?

• a.10 compressions to 2 breaths
• b.15 compressions to 2 breaths
• c.5 compressions to 1 breath
• d.30 compressions to 2 breaths✓

A single rescuer without an advanced airway uses 30 compressions to 2 breaths in an adult. Fifteen to two is the two-rescuer pediatric ratio, and the other ratios are not used in current practice.

An LPN/VN is suctioning a client's tracheostomy. How long should each suction pass last?

• a.No longer than 40 to 45 seconds
• b.Until the secretions have all cleared
• c.No longer than 25 to 30 seconds
• d.No longer than 10 to 15 seconds✓

Each pass is limited to 10 to 15 seconds because suction removes oxygen along with secretions. Longer passes and suctioning until clear both cause hypoxemia and can trigger bradycardia.

An LPN/VN is suctioning a client's tracheostomy. When should suction be applied?

• a.Continuously from insertion until removal
• b.While advancing the catheter into the airway
• c.Only after the catheter reaches the carina
• d.While withdrawing and rotating the catheter✓

Suction is applied on withdrawal to limit hypoxemia and mucosal injury. Applying it on insertion or continuously damages tissue, and advancing to the carina causes trauma and bradycardia.

An LPN/VN finds a client's chest tube disconnected from the drainage system. What should the LPN/VN do first?

• a.Notify the nursing supervisor that the tube came apart
• b.Tape the two ends together and check for bubbling
• c.Clamp the chest tube close to the chest wall
• d.Place the open end in sterile water at the bedside✓

Submerging the end creates a temporary water seal that stops air from entering the pleural space. Reporting, clamping, and reconnecting a contaminated end all risk a tension pneumothorax or infection.

An LPN/VN is caring for a client with a chest tube and observes continuous bubbling in the water seal chamber. What does this indicate?

• a.Obstruction of the tubing by a clot or debris
• b.An air leak in the system or the client✓
• c.Full reexpansion of the client's collapsed lung
• d.Normal function of the chest drainage system

Continuous bubbling in the water seal chamber signals an air leak that must be located. Intermittent bubbling with exhalation is normal, reexpansion produces no bubbling and no tidaling, and obstruction stops both bubbling and tidaling.

An LPN/VN is caring for a client receiving peritoneal dialysis and notes that the drained effluent is cloudy. What should the LPN/VN do?

• a.Record the finding and complete the next exchange
• b.Increase the dwell time for the next exchange
• c.Warm the next dialysate bag before instilling it
• d.Report the cloudy effluent to the registered nurse✓

Cloudy effluent is the classic early sign of peritonitis and must be reported so a specimen can be obtained and treatment started. Changing the dwell, warming the solution, and simply documenting all allow an infection to progress.

An LPN/VN is caring for a client with an arteriovenous fistula in the left arm. Which action is correct?

• a.Draw the morning blood work from the fistula
• b.Start an intravenous line in the left forearm
• c.Take blood pressures in the client's left arm
• d.Take blood pressures in the client's right arm✓

The fistula arm is protected from compression and punctures so the access stays patent. Cuff pressure, an intravenous start, and a venipuncture in that arm can all thrombose the access.

An LPN/VN checks a client's arteriovenous fistula and finds no thrill on palpation. What should the LPN/VN do?

• a.Document the finding and check again before dialysis
• b.Report the absent thrill to the nurse at once✓
• c.Apply a warm compress and recheck in one hour
• d.Elevate the arm on a pillow and observe the site

A missing thrill suggests the access has clotted, which is a time-sensitive problem. Warm compresses, elevation, and delayed rechecks all consume the time in which the access might be salvaged.

An LPN/VN is caring for a client with a Jackson-Pratt drain. How is suction maintained?

• a.Clamp the drain tubing between the emptying times
• b.Compress the bulb before recapping it each time✓
• c.Attach the bulb to low continuous wall suction
• d.Leave the bulb expanded so drainage flows freely

Squeezing the bulb before recapping creates the negative pressure that pulls drainage. Wall suction is not used, an expanded bulb exerts no suction, and clamping stops drainage altogether.

An LPN/VN is caring for a client whose surgical wound edges have separated with a loop of bowel visible. What should the LPN/VN do first?

• a.Apply a dry pressure dressing over the open area
• b.Cover the area with sterile saline-moistened gauze✓
• c.Notify the nursing supervisor about the open wound
• d.Push the exposed tissue gently back into the wound

Evisceration is covered with sterile moist gauze to keep the tissue viable while help is summoned and the client is kept still. Reporting first, replacing the tissue, and drying the exposed bowel all cause harm.

An LPN/VN is caring for a client with a tracheostomy who suddenly becomes restless with noisy breathing. What should the LPN/VN do first?

• a.Suction the tracheostomy to clear the airway✓
• b.Notify the registered nurse about the restlessness
• c.Raise the head of the bed and observe the client
• d.Increase the oxygen flow rate through the collar

Noisy breathing with restlessness in a client with a tracheostomy usually means secretions are obstructing the airway, and suctioning is within LPN/VN scope. Reporting, adding oxygen past an obstruction, and repositioning all leave the airway blocked.

An LPN/VN is caring for a client whose temperature is 35.1 degrees Celsius after surgery. Which measure should the LPN/VN use?

• a.Apply warmed blankets and cover the client's head✓
• b.Rub the client's arms and legs briskly with a towel
• c.Give a hot beverage while the client is still drowsy
• d.Place a heating pad on high under the client

Passive external warming with warmed blankets and head covering restores temperature safely. Vigorous rubbing can trigger arrhythmias, a heating pad under a client causes burns, and oral fluids are unsafe in a drowsy client.

An LPN/VN is performing a dressing change on a wound ordered to be packed. Which action is correct?

• a.Place a single large piece across the wound top
• b.Fill the cavity level with the surrounding skin
• c.Pack the gauze tightly into the cavity
• d.Pack the gauze loosely into the wound cavity✓

Loose packing keeps the cavity open for drainage without pressure on the wound bed. Tight packing impairs perfusion, filling level with the skin macerates the edges, and a cover piece does not pack the cavity.

An LPN/VN is caring for a client with a colostomy in the descending colon. Which stoma finding should be reported?

• a.A stoma that has become dusky purple in color✓
• b.A stoma that is pink and moist at the surface
• c.Slight swelling of the stoma in the first days
• d.A small amount of bleeding when it is cleaned

A dusky or purple stoma indicates impaired blood supply and possible necrosis. A pink moist stoma, minor bleeding from the vascular mucosa during cleaning, and early edema are all expected.

An LPN/VN is caring for a client on a ventilator and the high pressure alarm sounds. What is the most likely cause?

• a.An increase in the client's tidal volume
• b.Secretions obstructing the client's airway✓
• c.A leak around the endotracheal tube cuff
• d.A disconnection of the ventilator circuit

A high pressure alarm means resistance has increased, most often from secretions, biting, or a kink. A disconnection, a cuff leak, and a larger delivered volume all lower circuit pressure and trigger the low pressure alarm.

An LPN/VN is caring for a client with a permanent pacemaker. Which finding should be reported?

• a.A pulse of 48 with reports of light-headedness✓
• b.A pulse of 72 that is regular at rest
• c.A small bruise under the skin near the device
• d.Mild soreness at the insertion site on day one

A rate below the pacemaker's set rate with symptoms suggests the device is not capturing. A normal paced rate, early incisional soreness, and a small hematoma are expected findings.

An LPN/VN observes a client's cardiac monitor and sees a chaotic waveform with no identifiable complexes. The client is unresponsive. What should the LPN/VN do first?

• a.Obtain a full set of vital signs and a rhythm strip
• b.Check the electrodes and lead connections
• c.Start compressions and call for the defibrillator✓
• d.Notify the nursing supervisor about the rhythm change

An unresponsive client with a chaotic rhythm is in ventricular fibrillation and needs compressions and early defibrillation. Reporting, checking leads, and gathering vital signs all delay the only treatments that work.

An LPN/VN is reinforcing education for a client going home with a new tracheostomy. Which instruction should be included?

• a.Swim in a shallow pool with the neck kept above water
• b.Seal the stoma with an adhesive patch when outdoors
• c.Cover the stoma with a loose cloth when going outside✓
• d.Use a cotton ball taped over the stoma while sleeping

A loose breathable cover filters air without blocking it. Sealing the stoma obstructs breathing, swimming risks drowning through the stoma, and cotton fibers can be inhaled into the airway.

An LPN/VN is caring for a client with heart failure. Which finding suggests worsening fluid overload?

• a.A report of thirst after a salty evening meal
• b.A weight gain of 2 kilograms since yesterday✓
• c.Ankle swelling that resolves with overnight rest
• d.A weight gain of 2 kilograms over two months

Rapid weight gain of about 2 kilograms in a day reflects retained fluid, not tissue. Slow gain, dependent edema that clears overnight, and thirst after salt are not signs of decompensation.

An LPN/VN is caring for a client with chronic obstructive pulmonary disease who is receiving oxygen at 2 liters per minute by nasal cannula. The client reports increased breathlessness. What should the LPN/VN do first?

• a.Notify the nursing supervisor about the breathlessness
• b.Ask the client to breathe through the mouth
• c.Increase the oxygen flow rate to 6 liters per minute
• d.Raise the head of the bed and check the saturation✓

Positioning to ease the work of breathing and measuring the saturation are immediate LPN/VN actions that also produce the data any next step needs. Reporting first, raising the flow without an order, and rapid mouth breathing all fail the client.

An LPN/VN is removing skin staples from a healed surgical incision as ordered. Which finding should stop the procedure?

• a.A small amount of serous fluid appears at one end
• b.The incision line looks pink along its full length
• c.The wound edges separate as staples come out✓
• d.The client reports a pinching feeling with removal

Separation of the wound edges means the incision is not strong enough, and the remaining staples stay in place while the finding is reported. A pink line, a pinching sensation, and scant serous fluid are all expected.

An LPN/VN is caring for a client with a serum sodium of 122 mEq/L. Which finding should the LPN/VN expect?

• a.Extreme thirst with dry, sticky mucous membranes
• b.Increased urine output with a high specific gravity
• c.Flushed dry skin with a low-grade fever
• d.Confusion with muscle weakness and headache✓

Hyponatremia causes cerebral cell swelling, producing confusion, weakness, and headache. Intense thirst with dry membranes, flushed skin with fever, and concentrated high-volume urine all point toward hypernatremia or dehydration instead.

An LPN/VN is providing care for a client receiving hemodialysis three times weekly. Which food choice on the tray should be replaced?

• a.The baked potato served with the dinner✓
• b.The serving of applesauce with the meal
• c.The slice of white bread with the meal
• d.The white rice served with the dinner meal

Potatoes are high in potassium, which a dialysis client cannot excrete between treatments. White rice, white bread, and applesauce are all low in potassium.

An LPN/VN is caring for a client with a wound drainage device and the ordered dressing supplies are not stocked anywhere in the facility. What should the LPN/VN do?

• a.Delay the dressing change until the next work shift
• b.Reuse the outer layer of the current dressing again
• c.Ask the nursing supervisor to obtain the supplies✓
• d.Substitute the closest dressing available on the unit

When ordered supplies are unavailable facility-wide, the chain of command arranges procurement. Substituting a different product, postponing ordered care, and reusing a soiled dressing all change the treatment without authority.

An LPN/VN is caring for a client with a nasogastric tube who begins coughing and has a drop in oxygen saturation during a feeding. What should the LPN/VN do first?

• a.Stop the feeding and raise the head of the bed✓
• b.Notify the nursing supervisor about the coughing
• c.Slow the feeding rate and continue to observe
• d.Flush the tube with water to confirm patency

Stopping the infusion and elevating the head are the immediate actions that limit aspiration. Reporting, flushing, and slowing the rate all continue delivering formula into a possibly compromised airway.

An LPN/VN is reinforcing education with a client who has a new ileal conduit. Which statement indicates correct understanding?

• a.I will limit my fluids to reduce the output
• b.I will empty the pouch when it is one-third full✓
• c.I will change the pouch late in the evening
• d.I will expect the urine to be free of mucus

Emptying at one-third full protects the seal from the weight of urine. Pouch changes are easiest when output is lowest in the morning, fluids are encouraged to flush the conduit, and mucus in the urine is expected because bowel tissue produces it.