pg. 1 Latest NCLEX RN Exam Prep Test Bank 2025-2026 With 350 Exam Prep Questions and Correct Answers With Detailed Rationales | RN NCLEX Exam Most Recent Practice Test Bank 2025-2026 (New!)
The nurse in the emergency department is caring for a 41-year-old male client.
Nurse's Notes:
11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for
- week. Client states "The abdominal pain started after my 7-year-old child
accidentally kicked me in the stomach." Client plays soccer with the child once a
week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry
reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions.
For each assessment finding below, click to specify if the finding is consistent with the disease process of bowel obstruction, appendicitis, or ruptured spleen. Each finding may support more than 1 disease process.
Answer:
Bowel obstruction: Appetite, Bowel Pattern, Gastrointestinal Symptoms.
Appendicitis: Pain level.
Ruptured Spleen: Pain level.
The nurse in the emergency department is caring for a 41-year-old male client.
Nurse's Notes:
11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for 1 / 4
pg. 2 the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for
- week. Client states "The abdominal pain started after my 7-year-old child
accidentally kicked me in the stomach." Client plays soccer with the child once a
week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry
reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions.
Select the 3 complications the client is at risk for developing.•Anemia •Peritonitis •Septic Shock •Hypovolemia •Dysrhythmias •Cardiac Arrest
Answer:
•Anemia •Peritonitis •Septic Shock The nurse in the emergency department is caring for a 41-year-old male client.
Nurse's Notes:
11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for
- week. Client states "The abdominal pain started after my 7-year-old child
accidentally kicked me in the stomach." Client plays soccer with the child once a
week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry
reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions.
The nurse has reviewed the Nurses' Notes from 11:30.
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
Answers:
Indicated: 2 / 4
pg. 3 •Clear liquid diet •Soapsuds enema •Abdominal girth measurements •Abdominal Computed Tomography (CT) scan
NOT indicated:
•Heating pad to abdomen
The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral ulcer. Which is the most appropriate activity for the RN to delegate to the LPN?
1.Place the client in a side-lying position.
2.Initiate wound care protocol for standardized ulcer care.
3.Meet with the wound specialist to identify measures to improve healing.
4.Determine which treatments would best meet the healing needs of the client.
1.Place the client in a side-lying position.Rationale: The client with a diabetic ulcer needs to take strict precautions and implement very specific measures to allow for wound healing. Interventions include washing the feet with warm (not hot) water daily with a mild soap, using lanolin to prevent drying and cracking, wearing closed-toed shoes that are well fitting and avoiding high-heel and open-toed shoes, and exercising the feet daily by walking and flexing at the ankle to promote circulation.The nurse has attended a staff education program about caring for clients who are receiving positive pressure mechanical ventilation.Which of the following statements by the nurse would indicate a correct understanding of the teaching?
- "Clients should avoid range-of motion (ROM) exercises until weaned from
- "Clients may develop stress ulcers and gastrointestinal bleeding." 3 / 4
ventilation."
pg. 4
- "Clients will be chemically paralyzed to improve oxygenation."
- "Clients will experience diuresis and polyuria."
- "Clients may develop stress ulcers and gastrointestinal bleeding."
Rationale:
Positive pressure ventilation increases the likelihood of developing stress ulcers and bleeding.The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit to make a bed available.It would be most appropriate for the nurse to transfer the client who is
- 28-years-old, had a right mastectomy and has a closed-wound drainage system.
- 49-years-old, has diabetes mellitus (type 2) and has begun receiving insulin.
- 56-years-old, has hepatitis C (HCV) and has been afebrile for 24 hours.
- 70-years-old, has a fractures left tibia and had an external fixation device applied
- 56-years-old, has hepatitis C (HCV) and has been afebrile for 24 hours.
- First stage of labor who has an oral temperature of 99.7F (37.6 C)
- First stage of labor whose contractions are occurring every 30 seconds
- Second stage of labor who has respirations of 26.
- Second stage of labor whose contractions are lasting for 60 seconds.
- First stage of labor whose contractions are occurring every 30 seconds
48 hours ago.
The nurse has been made aware of the following client situations.The charge nurse has received a change-of-shift report on the following clients in labor.The charge nurse should ask a staff member to first see the client in the
Rationale:
- Elevated temperature is normal during labor.
- Increased respirations are normal during labor "pant-pant-blow" "hee-hee-hoo"
- / 4
breathing pattern.