NCLEX-PN Nursing — All Questions

Before administering a medication, the LPN/LVN should verify at least how many client identifiers?

• a.One
• b.Five
• c.Two✓
• d.Four

The standard of care requires at least two client identifiers, such as name and date of birth, before medication administration. The room number is not an acceptable identifier. Correct identification prevents wrong-client errors.

A client is placed on contact precautions for Clostridioides difficile. Which action is essential?

• a.Wear an N95 respirator when entering the room
• b.Keep the client's door closed with negative pressure
• c.Use alcohol-based hand rub only
• d.Wash hands with soap and water after removing gloves✓

C. difficile spores are not reliably killed by alcohol, so hand washing with soap and water is required. An N95 and negative-pressure room are for airborne precautions, not contact. Gloves and gowns are also used for contact precautions.

The LPN/LVN finds a small fire in a trash can in a client's room. Using the RACE acronym, what is the first action?

• a.Rescue the client from immediate danger✓
• b.Extinguish the fire before doing anything else
• c.Contain the fire by closing the door first
• d.Activate the alarm and wait for the fire team

RACE stands for Rescue, Alarm, Contain, and Extinguish. The first priority is to rescue anyone in immediate danger from the fire. Only after people are safe does the nurse activate the alarm, contain, and extinguish.

Which client is at highest risk for falls and should have safety precautions reinforced?

• a.A 40-year-old awaiting routine discharge this afternoon
• b.An 80-year-old on sedatives with a history of dizziness✓
• c.A 25-year-old admitted overnight for observation
• d.A 30-year-old ambulating independently without aids

Advanced age, sedating medications, and a history of dizziness are major fall-risk factors. Independent younger clients without these factors are at lower risk. Fall precautions such as a low bed and call light within reach are indicated.

The LPN/LVN is about to use a fire extinguisher. Using the PASS technique, what is the first step?

• a.Sweep side to side
• b.Squeeze the handle
• c.Pull the pin✓
• d.Aim at the flames

PASS stands for Pull, Aim, Squeeze, and Sweep. The first step is to pull the safety pin. Then the nurse aims at the base of the fire, squeezes the handle, and sweeps side to side.

A client requires airborne precautions for pulmonary tuberculosis. Which personal protective equipment is required to enter the room?

• a.A face shield only
• b.A standard surgical mask
• c.A gown and gloves only
• d.A fitted N95 respirator✓

Airborne precautions for tuberculosis require a fitted N95 respirator and a negative-pressure room. A standard surgical mask does not filter the small airborne droplet nuclei. Respiratory protection is essential to prevent transmission.

The LPN/LVN prepares to move a heavy client up in bed. Which action best protects the nurse from injury?

• a.Use a friction-reducing device and get help✓
• b.Move the client alone quickly
• c.Keep the feet close together for balance
• d.Bend at the waist and lift with the back

Using a friction-reducing device and additional staff reduces strain and prevents injury. Lifting with the back and working alone increase injury risk. A wide base of support and using leg muscles also protect the nurse.

Which action reduces the risk of a medication error during administration?

• a.Preparing medications for several clients at once and giving them later
• b.Checking the medication label against the order three times✓
• c.Relying on memory instead of the medication record
• d.Leaving medications at the bedside for the client to take later

Checking the label against the order three times and following the rights of administration reduces errors. Pre-pouring for multiple clients and leaving medications at the bedside increase risk. Medications should be given and documented immediately.

A client with a seizure disorder begins to have a generalized seizure. What is the priority nursing action?

• a.Hold the client firmly to stop the movements
• b.Protect the head and turn the client to the side✓
• c.Insert a padded tongue blade into the mouth
• d.Restrain the client's arms and legs

During a seizure the nurse protects the client from injury by cushioning the head and turning them to the side to maintain the airway. Nothing should be forced into the mouth, and the client should not be restrained. Movements should not be held back.

The LPN/LVN receives a client's meal tray. Before assisting with feeding, what should the nurse verify first?

• a.Whether the client would prefer to eat the dessert first
• b.The client's name against the diet order and tray card✓
• c.The temperature of the food and beverages on the tray
• d.The client's favorite foods and least-liked items

The nurse must confirm the tray matches the correct client and the prescribed diet before feeding, preventing errors such as giving a regular diet to a client who is NPO. Food temperature and preferences are secondary. Matching client to order is a core safety check.

Which finding requires the LPN/LVN to question the use of physical restraints?

• a.Regular monitoring of skin and circulation
• b.A current provider order specifying type and duration
• c.Documentation of less restrictive measures tried first
• d.The restraint was applied only for staff convenience✓

Restraints may never be used for staff convenience or discipline. They require a time-limited provider order, trial of less restrictive alternatives, and frequent monitoring. Using restraints for convenience is unsafe and unethical.

The LPN/LVN notes a client's oxygen is in use. Which safety instruction is most important?

• a.Post 'no smoking' signs and keep oxygen away from open flames✓
• b.Allow smoking in the room as long as the window is open
• c.Use petroleum-based lip balm freely to prevent dry lips
• d.Store the oxygen tank lying flat on the floor beside the bed

Oxygen supports combustion, so open flames and smoking must be prohibited and clearly posted. Petroleum-based products near oxygen are a fire hazard, and tanks should be secured upright. Fire prevention is the priority with oxygen therapy.

A client's identification band is missing at the time of a blood glucose check. What should the LPN/LVN do first?

• a.Proceed using the room number as identification
• b.Ask the client next door to confirm the client's name
• c.Skip the check until the next shift
• d.Verify identity and apply a new band before proceeding✓

A missing identification band must be replaced after verifying identity before care that depends on correct identification. Room numbers and other clients are not reliable identifiers. Accurate identification prevents errors.

Which practice best prevents catheter-associated urinary tract infection?

• a.Routinely irrigating the catheter every shift
• b.Disconnecting the tubing to collect samples
• c.Placing the drainage bag on the client's abdomen during transport
• d.Keeping the drainage bag below the level of the bladder✓

Keeping the drainage bag below bladder level prevents backflow of urine and reduces infection risk. Unnecessary irrigation and breaking the closed system increase infection risk. Maintaining a closed, dependent drainage system is key.

Before giving any medication, the nurse must verify the client's identity using at least how many identifiers?

• a.Two, such as name and date of birth✓
• b.The room and bed number
• c.Three separate photo IDs
• d.One, if the client answers to their name

Use at least two identifiers, such as name and date of birth. The room or bed number and a single verbal response to a name are unsafe, and three photo IDs is not the standard.

A client with suspected active tuberculosis is admitted. Which precautions are required?

• a.Contact precautions with gloves and gown only
• b.Standard precautions alone
• c.Airborne precautions with an N95 respirator and a negative-pressure room✓
• d.Droplet precautions with a surgical mask worn within close range of the client

Active TB spreads by airborne droplet nuclei, requiring airborne precautions — an N95 respirator and a negative-pressure room. A surgical mask handles droplet organisms; gloves and gown alone handle contact organisms.

A nurse is caring for a client with Clostridioides difficile. Which action is correct?

• a.Place the client in a negative-pressure room
• b.Use alcohol-based hand rub after care
• c.Wear an N95 respirator during care
• d.Wash hands with soap and water after removing gloves✓

*C. difficile* forms spores that alcohol does not kill, so wash with soap and water. Alcohol rub is inadequate, and because *C. difficile* is a contact organism, a negative-pressure room and an N95 respirator are not indicated.

A nurse discovers a fire in a client's trash can. According to RACE, what is the first action?

• a.Activate the alarm at the pull station
• b.Extinguish the fire with the nearest extinguisher
• c.Rescue any client in immediate danger✓
• d.Contain the fire by closing doors

In RACE, the first step is Rescue anyone in immediate danger, then Activate the alarm, Contain, and Extinguish/Evacuate. Rescuing people comes before alarms or extinguishers.

A restrained client requires which of the following?

• a.Indefinite orders that do not need renewal
• b.A time-limited provider order and frequent monitoring✓
• c.Restraints applied for staff convenience during busy shifts
• d.Restraints used before any less-restrictive alternatives

Restraints require a time-limited provider order and frequent monitoring, with less-restrictive alternatives tried first. They are never applied for convenience, never ordered indefinitely, and never used before alternatives.

During a generalized seizure, the nurse should:

• a.Turn the client to the side and cushion the head✓
• b.Hold the client still until movements stop
• c.Restrain the arms and legs to prevent injury
• d.Insert a padded tongue blade to protect the tongue

During a seizure, turn the client to the side and cushion the head to protect the airway and prevent injury. Never insert anything into the mouth, and never restrain or hold the client still.

Before administering a medication, a client says the pill "looks different from the one I usually take." The nurse should:

• a.Hold the medication and verify the order and drug✓
• b.Ask the client to take it and report any effects
• c.Give a partial dose to be safe
• d.Reassure the client and give it as scheduled

When a client questions a medication, hold it and verify the order and drug before giving. Reassuring the client and giving it anyway, giving it and watching for effects, or improvising a partial dose all risk a medication error.

Which action correctly follows standard precautions?

• a.Reuse gloves between two stable clients to save supplies
• b.Wear gloves only for clients with a known infection
• c.Perform hand hygiene before and after every client contact✓
• d.Recap needles by hand before disposal

Standard precautions include hand hygiene before and after every client contact. Recapping needles by hand, gloving only for known infections, and reusing gloves between clients all violate standard precautions.

An LPN/VN is reinforcing safety education with a client who uses oxygen at home. Which client statement requires follow-up?

• a.I keep petroleum jelly by my chair for dry lips✓
• b.I use a cotton blanket instead of my wool one
• c.I moved my recliner away from the gas stove
• d.I put a no-smoking sign on my front door

Petroleum-based products are flammable in an oxygen-enriched environment and are replaced with water-based products. Moving away from an open flame, posting a no-smoking sign, and choosing cotton over wool are all correct home oxygen precautions.

A client has Clostridioides difficile infection. What should the LPN/VN do after removing gloves and leaving the room?

• a.Use alcohol-based rub and then don clean gloves
• b.Wash the hands with soap and running water✓
• c.Apply alcohol-based hand rub for twenty seconds
• d.Rinse the hands and apply hand cream

C. difficile spores are not killed by alcohol, so hand hygiene after caring for these clients uses soap and water, which physically removes spores. Alcohol-based rub alone, with cream, or followed by gloves leaves spores on the hands.

An LPN/VN discovers a fire in a client's waste basket. What should the LPN/VN do first?

• a.Move the client out of the room to a safe area✓
• b.Close the door of the room to contain the fire
• c.Notify the nursing supervisor of the fire in the room
• d.Use the extinguisher stored in the hallway alcove

The RACE sequence begins with rescue: remove anyone in immediate danger. Reporting, containing the fire by closing the door, and extinguishing all follow, and each of them leaves the client in the room while it is done.

An LPN/VN checks a client who is in bilateral wrist restraints and finds the right hand cool, pale, and swollen. What should the LPN/VN do first?

• a.Document the skin color and temperature of the hand
• b.Release the right wrist restraint to restore circulation✓
• c.Report the circulatory finding to the nursing supervisor
• d.Reposition the client's arm on a pillow for support

Compromised circulation under a restraint is corrected immediately by releasing that restraint; the LPN/VN does not need an order to remove a restraint for safety. Reporting, documenting, and repositioning all leave the constricted limb in place.

An LPN/VN prepares to transfer a client from bed to a wheelchair. Which action protects the LPN/VN from injury?

• a.Hold the client at arm's length while turning
• b.Keep the knees straight and pivot from the waist
• c.Keep the feet apart and bend the knees✓
• d.Twist the trunk toward the chair while lifting

A wide base of support with flexion at the knees and hips uses the strong leg muscles and keeps the load close. Straight knees, an extended reach, and trunk twisting all place the load on the lumbar spine.

A client's chart lists an allergy to shellfish. The provider orders a contrast study for the afternoon. What should the LPN/VN do?

• a.Report the documented allergy before the study is scheduled✓
• b.Record the allergy again on the front of the paper chart
• c.Ask the client whether an antihistamine has ever been taken
• d.Confirm that the allergy band is on the client's wrist

An allergy that may bear on an ordered test is reported so the provider can evaluate the order before the client is sent. Checking the band, taking a medication history, and re-recording the allergy do not inform the prescriber.

An LPN/VN finds an oxygen cylinder standing unsecured next to a client's bed. What should the LPN/VN do first?

• a.Notify the nursing supervisor about the loose cylinder
• b.Ask respiratory therapy to remove it
• c.Post a sign advising staff that the cylinder is loose
• d.Secure the cylinder in an upright holder or rack✓

An unsecured compressed gas cylinder can fall and rupture, so it is stabilized immediately by anyone who finds it. Reporting, posting a warning, and requesting a pickup all leave a projectile hazard beside the client.

An LPN/VN is preparing to perform a sterile dressing change and drops a sterile gauze pad on the edge of the sterile field. What should the LPN/VN do?

• a.Move the pad toward the center of the sterile field
• b.Continue the dressing change and note the contamination
• c.Discard the pad and add a new one to the field✓
• d.Pick the pad up with sterile forceps and reposition it

The outer inch of a sterile field is considered contaminated, so an item that lands there is discarded. Moving it inward, handling it with forceps, and proceeding anyway all carry contamination into the wound.

An infant abduction alert is announced in a hospital. What should the LPN/VN on a medical unit do?

• a.Monitor the assigned exit and observe anyone leaving✓
• b.Notify the nursing supervisor that the alert was heard
• c.Move all clients on the unit into their rooms and wait
• d.Telephone the obstetric unit for a description

Security alerts assign every staff member a post so all exits are covered. Acknowledging the alert, sheltering clients, and telephoning the source unit all leave an exit unwatched during the minutes that matter.

An LPN/VN is preparing to give an intramuscular injection and the client suddenly pulls away, causing the used needle to scratch the LPN/VN's forearm. What should the LPN/VN do first?

• a.Wash the exposed area with soap and running water✓
• b.Ask the client to consent to bloodborne pathogen testing
• c.Complete an occupational exposure incident report form
• d.Report the exposure to the nursing supervisor

First aid after a sharps exposure begins with washing the site. Reporting, completing the exposure form, and arranging source testing all follow immediately afterward but do not come before decontaminating the wound.

An LPN/VN enters a room and finds a client sitting on the edge of the bed, pale and beginning to slump toward the floor. What should the LPN/VN do first?

• a.Ask the client to describe how the dizziness started
• b.Call the nursing supervisor from the bedside telephone
• c.Raise the head of the bed and lower the side rails
• d.Ease the client to the floor while protecting the head✓

When a fall is already in progress, guiding the client down protects the head and prevents an uncontrolled drop. Telephoning, adjusting the bed, and taking a history all leave the client falling unassisted.

An LPN/VN is caring for a client on contact precautions for a multidrug-resistant organism. What should the LPN/VN do when leaving the room?

• a.Remove the gloves in the room and the gown in the hallway
• b.Remove the gown and gloves just outside the doorway
• c.Carry the used gown to the soiled utility room to discard
• d.Remove the gown and gloves inside the client's room✓

Contaminated personal protective equipment is removed and discarded inside the room so organisms are not carried into the corridor. Doffing outside the door, transporting the gown, and splitting the removal all move contamination out of the room.

A client who has a seizure disorder begins a generalized tonic-clonic seizure while lying in bed. What should the LPN/VN do?

• a.Turn the client to the side and protect the head✓
• b.Insert a padded tongue blade between the teeth
• c.Call the nursing supervisor before touching the client
• d.Hold the client's arms still to prevent an injury

Side-lying positioning protects the airway and padding protects the head. Restraining the limbs can cause fractures, placing an object in the mouth can break teeth or obstruct the airway, and leaving the bedside to make a call abandons an unprotected client.

An LPN/VN is assigning care and the unlicensed assistive personnel reports that a bed alarm on a high fall-risk client has been turned off. What should the LPN/VN do first?

• a.Notify the nursing supervisor that the alarm was off
• b.Ask the assistive personnel who turned the alarm off
• c.Turn the bed alarm back on and check the client✓
• d.Add a note to the shift report about the alarm setting

The protection is restored first, and the client is checked because the alarm may have been silent during a fall. Reporting, investigating who did it, and noting it in report all leave the client unprotected in the meantime.

An LPN/VN must apply a soft wrist restraint to a client who is pulling at an endotracheal tube. Which action is correct?

• a.Secure the restraint tie to the movable bed frame✓
• b.Attach the restraint tie to the mattress underneath
• c.Tie the restraint with a square knot at the wrist
• d.Secure the restraint tie to the upper side rail

Restraint ties are fastened to a part of the bed frame that moves with the bed, so raising or lowering the bed does not tighten them. A side rail moves independently, a square knot cannot be released quickly, and a tie under the mattress cannot be reached in an emergency.

During an external disaster response, an LPN/VN is asked to help triage arriving clients. Which client should be treated first?

• a.A client with severe pain and no visible external injury
• b.A client with an open fracture of the lower right leg
• c.A client with noisy, obstructed breathing and a weak pulse✓
• d.A client with a deep laceration that has stopped bleeding

Airway compromise with shock is immediately life-threatening and is treated first. An open fracture, a controlled laceration, and undifferentiated pain are all urgent but survivable during the minutes that airway management requires.

An LPN/VN is reinforcing home safety education with an older adult who lives alone. Which instruction should the LPN/VN include?

• a.Keep the hallway lights off to save energy
• b.Use a rolling stool to reach items on high shelves
• c.Remove loose throw rugs from the walking paths✓
• d.Place an extension cord along the edge of the hallway

Loose rugs are a leading cause of falls in the home. Darkened hallways, an unstable rolling stool, and a cord across a walking route each add a hazard rather than remove one.

An LPN/VN sees an unlicensed assistive personnel preparing to reuse a glucometer lancet device on a second client. What should the LPN/VN do first?

• a.Stop the procedure before the second client is tested✓
• b.Document the observation and review the device policy
• c.Ask the assistive personnel to explain the unit routine
• d.Report the practice to the nursing supervisor right away

A lancing device shared between clients transmits bloodborne pathogens, so the act is interrupted before it happens. Reporting, seeking an explanation, and documenting all allow the exposure to occur first.

An LPN/VN is caring for a client with a draining wound. Which personal protective equipment is required to change the saturated dressing?

• a.A surgical mask and gloves for the dressing change
• b.Gloves alone for a wound that is already covered
• c.A gown and mask without any gloves
• d.Gloves and a gown for the anticipated splash✓

Standard precautions require protection matched to the anticipated exposure, and a saturated dressing means contact with body fluid on the hands and clothing. Gloves alone, a mask substituting for a gown, and omitting gloves all leave a predicted exposure route open.

An LPN/VN notes that a client's identification band is missing during the morning medication pass. What should the LPN/VN do?

• a.Ask the client to state the full name and give the dose
• b.Give the medication and request a band from admitting
• c.Apply a new band after verifying the client's identity✓
• d.Ask a coworker who knows the client to confirm identity

Identity is verified and the band replaced before care continues, so every later encounter has the identifier available. A single verbal check, deferring the band, and relying on a coworker's recognition all leave the client unbanded.

An LPN/VN is preparing to move a client with limited weight-bearing from bed to a stretcher. Which device is appropriate?

• a.A gait belt applied around the client's waist and chest
• b.A draw sheet pulled by one staff member at the head
• c.A mechanical lift operated by a single staff member
• d.A friction-reducing slide board with two staff members✓

A lateral transfer to a stretcher uses a slide board with at least two people. A gait belt is for ambulation and standing, one person pulling a draw sheet risks shearing and injury, and a mechanical lift is not operated alone.

A client on droplet precautions must go to the radiology department. What should the LPN/VN do?

• a.Wrap the client in a clean sheet for the entire transport
• b.Ask radiology to come to the unit with portable equipment
• c.Have the transport staff wear N95 respirators
• d.Place a surgical mask on the client for transport✓

Source control with a surgical mask on the client contains respiratory droplets during transport. Respirators on staff are not the droplet-precaution requirement, a sheet does not contain droplets, and portable equipment is not always an option for the ordered study.

An LPN/VN finds a client's intravenous pump alarming with an occlusion message and the tubing kinked under the client's arm. What should the LPN/VN do first?

• a.Silence the alarm and recheck the pump in ten minutes
• b.Straighten the tubing and check that flow resumes✓
• c.Notify the nursing supervisor that the pump is alarming
• d.Increase the pump rate to overcome the resistance

A visible mechanical cause is corrected on the spot, which is within the LPN/VN's scope. Reporting a kink, silencing an alarm, and raising the rate against an occlusion all delay or worsen the problem.

An LPN/VN notices that a client's oxygen tubing runs across the doorway of the room. What should the LPN/VN do?

• a.Shorten the tubing by coiling it beside the bed
• b.Reroute the tubing away from the doorway✓
• c.Place a warning sign at the entrance to the room
• d.Tape the tubing to the floor across the doorway

Removing the tubing from the walking path eliminates the trip hazard. Taping it down still leaves a raised ridge, a sign relies on people reading it, and coiling excess tubing beside the bed can kink the oxygen flow.

An LPN/VN is assigned to perform safety checks on a client who is in seclusion. How often should the client be observed?

• a.At the beginning and the end of the seclusion period
• b.Once each hour while the client remains in seclusion
• c.Continuously, according to facility policy and the order✓
• d.Every thirty minutes until the seclusion is discontinued

A client in seclusion requires continuous monitoring in the manner the facility policy and order specify, because the client cannot summon help. Half-hourly, hourly, and start-and-end checks all leave long unobserved intervals.

An LPN/VN is caring for a client who has a latex allergy. Which action is appropriate?

• a.Ask the client to describe the reaction before changing supplies
• b.Wear powder-free latex gloves when giving direct care
• c.Remove latex items only from the client's bedside table
• d.Post the allergy and use latex-free supplies at the bedside✓

Latex is removed from the client's environment and the allergy is communicated to everyone entering the room. Powder-free latex is still latex, clearing one surface leaves other sources, and taking a history does not remove exposure.

An LPN/VN finds a spill of blood on the floor of a client's room. What should the LPN/VN do first?

• a.Ask housekeeping to bring a spill kit later
• b.Notify the nursing supervisor about the spill on the floor
• c.Wipe the spill with paper towels from the bedside table
• d.Contain the area so no one walks through the spill✓

Preventing contact and tracking comes first, before the spill is cleaned with the approved kit and disinfectant. Reporting, improvising with paper towels, and requesting a delayed cleanup all leave people walking through a bloodborne hazard.

An LPN/VN is preparing a client's room for a client on protective environment precautions after a stem cell transplant. Which action is appropriate?

• a.Limit the client to a single visitor at any one time
• b.Keep the door open so staff can observe the client
• c.Place a container of alcohol-based rub inside the room
• d.Remove fresh flowers and potted plants from the room✓

Fresh flowers and soil harbor Aspergillus and other fungi that endanger a severely neutropenic client. Hand rub, visitor limits, and an open door do not address that specific hazard, and an open door defeats the positive-pressure airflow.

An LPN/VN observes that a newly hired assistive personnel is not wearing gloves while emptying a urinary drainage bag. What should the LPN/VN do?

• a.Report the practice to the registered nurse later
• b.Ask whether the person received training on standard precautions
• c.Ask the person to stop and put on gloves before continuing✓
• d.Empty the remaining drainage bags on the unit personally

An unsafe practice in progress is stopped immediately, then addressed through education and reporting. A delayed report, a training question, and taking over the rest of the task all allow this exposure to be completed.

An LPN/VN is asked to check that emergency suction equipment at a bedside is ready for use. Which finding indicates the equipment is ready?

• a.The catheter package at the bedside is sealed and dry
• b.The suction tubing is coiled and connected to the wall
• c.The suction generates the set pressure when occluded✓
• d.The collection canister is empty and correctly seated

Only occluding the tubing and watching the gauge reach the set pressure demonstrates that the system actually works. An empty canister, connected tubing, and an intact catheter package are all necessary but none of them tests function.