NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2026
1. Questions
1. 1.ID: 9477047208
A client who has undergone abdominal surgery calls the nurse and reports
that she just felt “something give way” in the abdominal incision. The
nurse checks the incision and notes the presence of wound dehiscence.
The nurse should take which immediate action?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover the abdominal wound with a sterile dressing moistened with
sterile saline solution Correct
1. Rationale: Wound dehis
2. Questions
1. 1.ID: 9477047208
A client who has undergone abdominal surgery calls the nurse and reports
that she just felt “something give way” in the abdominal incision. The
nurse checks the incision and notes the presence of wound dehiscence.
The nurse should take which immediate action?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover the abdominal wound with a sterile dressing moistened with
sterile saline solution Correct
Giddens Concepts: Caregiving, Tissue Integrity
Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence
HESI Concepts: Caregiving, Tissue Integrity
occurs, the nurse
Reference: Lewis,immediately places
S., Dirksen, S., the clientM.,
Heitkemper, in a&low Fowler’s
Bucher, positionMedical-surgical
L. (2014). or supine with the knees
nursing:
bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying
Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The
Awarded 1.0 points out of 1.0 possible points.
health care provider is notified, and the nurse documents the occurrence and the nursing actions
that were implemented in response.
,2. 2.ID: 9477054249
A client who just returned from the recovery room after a tonsillectomy
and adenoidectomy is restless and the pulse rate is increased. As the
nurse continues the assessment, the client begins to vomit a copious
amount of bright-red blood. The nurse should take which immediate
action?
A. Notify the surgeon Correct
B. Continue the assessment
C. Check the client’s blood pressure
D. Obtain a flashlight, gauze, and a curved hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the
client vomits a large amount of bright-red blood or the pulse rate increases and the patient is
restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,
gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse
should also gather additional assessment data, but the surgeon must be contacted immediately.
Test-Taking Strategy: Note the strategic word, immediate. Noting the words “brightred blood” will
assist in directing you to the correct option. Remember that the presence of bright-red blood
indicates active bleeding. Review the nursing actions to be taken immediately when bleeding occurs
after a tonsillectomy and adenoidectomy
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Collaboration, Clotting
HESI Concepts: Collaboration/Managing Care, Perfusion-Clotting
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered
collaborative care. (7th ed., p. 644). St. Louis: Saunders.
Awardedx1.0xpointsxoutxofx1.0xpossiblexpoints.
3. 3.ID:x9477051455
Axclientxwhoxhasxjustxundergonexsurgeryxsuddenlyxexperiencesxchestxpain,xd
yspnea,xandxtachypnea.xThexnursexsuspectsxthatxthexclientxhasxaxpulmonaryx
embolismxandximmediatelyxsetsxaboutxtoxtakexwhichxaction?
, A. Preparingxthexclientxforxaxperfusionxscan
B. Attachingxthexclientxtoxaxcardiacxmonitor
C. AdministeringxoxygenxbyxwayxofxnasalxcannulaxCorrect
D. Ensuringxthatxthexintravenousx(IV)xlinexisxpatent
Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately
administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the
health care provideris notified. IV infusion lines are needed to administer medications or fluids. A
perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the
presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial
blood gas determinations drawn. The immediate priority, however, is the administration of oxygen.
Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Use the ABCs
(airway, breathing, and circulation) to find the correct option. Review the nursing actions to be taken
immediately in the event of pulmonary embolism
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Perfusion, Clotting
HESI Concepts: Oxygenation/Gas Exchange, Perfusion-Clotting
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby.
Awardedx1.0xpointsxoutxofx1.0xpossiblexpoints.
4. 4.ID:x9477051498
Axnursexisxassessingxaxclientxwhoxhasxaxclosedxchestxtubexdrainagexsystem.
xThexnursexnotesxconstantxbubblingxinxthexwaterxsealxchamber.xWhatxactio
nsxshouldxthexnursextake?x(Selectxallxthatxapply).
A. Clampxthexchestxtube
B. Changxthexdrainagexsystem
C. AssessxthexsystemxforxanxexternalxairxleakxCorrect
D. Reducexthexdegreexofxsuctionxbeingxapplied
E. Documentxassessmentxfindings,xactionsxtaken,xandxclien
txresponsexCorrect
Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may
indicate the presence of an air leak. The nurse would assess the chest tube system for the presence
of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not
, becausexanxairxleakxmayxbexpresentxinxthexpleuralxspace.xLeakagexandxtrap
pingxofxairxinxthexpleuralxspacexcanxresultxinxaxtensionxpneumothorax.xClam
pingxthexchestxtubexisxincorrect.xAdditionally,xaxchestxtubexisxnotxclampedx
unlessxthisxhasxbeenxspecificallyxprescribedxinxthexagency’sxpoliciesxandxpr
ocedures.xChangingxthexdrainagexsystemxwillxnotxalleviatexthexproblem.xRe
ducingxthexdegreexofxsuctionxbeingxappliedxwillxnotxaffectxthexbubblingxinxt
hexwaterxsealxchamberxandxcouldxbexharmful.xThexnursexwouldxdocumentxt
hexassessmentxfindingsxandxinterventionsxtakenxinxthexclient’sxmedicalxreco
rd.
Test-TakingxStrategy:xFocusxonxthexdataxinxthexquestion,xnotingxthatxtherexi
sxbubblingxinxthexwaterxsealxchamber.xUsexknowledgexregardingxthexpriorityx
actionsxinxthexcarexofxaxclosedxchestxtubexdrainagexsystem.xRecallingxthatxthi
sxmayxindicatexanxairxleakxwillxdirectxyouxtoxthexcorrectxoptions.xReviewxthex
nursingxactionsxtoxbextakenximmediatelyxinxthexeventxthatxcomplicationsxofxax
closedxchestxtubexdrainagexsystemxoccur
LevelxofxCognitivexAbility:xApplying
ClientxNeeds:xPhysiologicalxIntegrity
IntegratedxProcess:xNursingxProcess/Implementation
ContentxArea:
CriticalxCare:xEmergencyx Situation/Management
GiddensxConcepts:xCarexCoordination,xGasxExchange
HESIxConcepts:x NursingxInterventions,x Oxygenation/GasxExchange
Reference:xLewis,xS.,xDirksen,xS.,xHeitkemper,xM.,x&xBucher,xL.x(2014).x
Medical-surgicalxnursing:xAssessmentxandxmanagementxofxclinicalxproble
msx(9thxxed.,xp.x546).xSt.xLouis:xMosby.
Awardedx2.0xpointsxoutxofx2.0xpossiblexpoints.
5. 5.ID:x9477055619
Axnursexisxhelpingxaxclientxwithxaxclosedxchestxtubexdrainagexsystemxgetxout
xofxbedxandxintoxaxchair.xDuringxthextransfer,xthexchestxtubexisxcaughtxonxthe
xlegxofxthexchairxandxdislodgedxfromxthexinsertionxsite.xWhatxisxtheximmediat
exnursingxaction?
A. Reinsertxthexchestxtube
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2026
1. Questions
1. 1.ID: 9477047208
A client who has undergone abdominal surgery calls the nurse and reports
that she just felt “something give way” in the abdominal incision. The
nurse checks the incision and notes the presence of wound dehiscence.
The nurse should take which immediate action?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover the abdominal wound with a sterile dressing moistened with
sterile saline solution Correct
1. Rationale: Wound dehis
2. Questions
1. 1.ID: 9477047208
A client who has undergone abdominal surgery calls the nurse and reports
that she just felt “something give way” in the abdominal incision. The
nurse checks the incision and notes the presence of wound dehiscence.
The nurse should take which immediate action?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover the abdominal wound with a sterile dressing moistened with
sterile saline solution Correct
Giddens Concepts: Caregiving, Tissue Integrity
Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence
HESI Concepts: Caregiving, Tissue Integrity
occurs, the nurse
Reference: Lewis,immediately places
S., Dirksen, S., the clientM.,
Heitkemper, in a&low Fowler’s
Bucher, positionMedical-surgical
L. (2014). or supine with the knees
nursing:
bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying
Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The
Awarded 1.0 points out of 1.0 possible points.
health care provider is notified, and the nurse documents the occurrence and the nursing actions
that were implemented in response.
,2. 2.ID: 9477054249
A client who just returned from the recovery room after a tonsillectomy
and adenoidectomy is restless and the pulse rate is increased. As the
nurse continues the assessment, the client begins to vomit a copious
amount of bright-red blood. The nurse should take which immediate
action?
A. Notify the surgeon Correct
B. Continue the assessment
C. Check the client’s blood pressure
D. Obtain a flashlight, gauze, and a curved hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the
client vomits a large amount of bright-red blood or the pulse rate increases and the patient is
restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,
gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse
should also gather additional assessment data, but the surgeon must be contacted immediately.
Test-Taking Strategy: Note the strategic word, immediate. Noting the words “brightred blood” will
assist in directing you to the correct option. Remember that the presence of bright-red blood
indicates active bleeding. Review the nursing actions to be taken immediately when bleeding occurs
after a tonsillectomy and adenoidectomy
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Collaboration, Clotting
HESI Concepts: Collaboration/Managing Care, Perfusion-Clotting
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered
collaborative care. (7th ed., p. 644). St. Louis: Saunders.
Awardedx1.0xpointsxoutxofx1.0xpossiblexpoints.
3. 3.ID:x9477051455
Axclientxwhoxhasxjustxundergonexsurgeryxsuddenlyxexperiencesxchestxpain,xd
yspnea,xandxtachypnea.xThexnursexsuspectsxthatxthexclientxhasxaxpulmonaryx
embolismxandximmediatelyxsetsxaboutxtoxtakexwhichxaction?
, A. Preparingxthexclientxforxaxperfusionxscan
B. Attachingxthexclientxtoxaxcardiacxmonitor
C. AdministeringxoxygenxbyxwayxofxnasalxcannulaxCorrect
D. Ensuringxthatxthexintravenousx(IV)xlinexisxpatent
Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately
administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the
health care provideris notified. IV infusion lines are needed to administer medications or fluids. A
perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the
presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial
blood gas determinations drawn. The immediate priority, however, is the administration of oxygen.
Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Use the ABCs
(airway, breathing, and circulation) to find the correct option. Review the nursing actions to be taken
immediately in the event of pulmonary embolism
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Perfusion, Clotting
HESI Concepts: Oxygenation/Gas Exchange, Perfusion-Clotting
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby.
Awardedx1.0xpointsxoutxofx1.0xpossiblexpoints.
4. 4.ID:x9477051498
Axnursexisxassessingxaxclientxwhoxhasxaxclosedxchestxtubexdrainagexsystem.
xThexnursexnotesxconstantxbubblingxinxthexwaterxsealxchamber.xWhatxactio
nsxshouldxthexnursextake?x(Selectxallxthatxapply).
A. Clampxthexchestxtube
B. Changxthexdrainagexsystem
C. AssessxthexsystemxforxanxexternalxairxleakxCorrect
D. Reducexthexdegreexofxsuctionxbeingxapplied
E. Documentxassessmentxfindings,xactionsxtaken,xandxclien
txresponsexCorrect
Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may
indicate the presence of an air leak. The nurse would assess the chest tube system for the presence
of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not
, becausexanxairxleakxmayxbexpresentxinxthexpleuralxspace.xLeakagexandxtrap
pingxofxairxinxthexpleuralxspacexcanxresultxinxaxtensionxpneumothorax.xClam
pingxthexchestxtubexisxincorrect.xAdditionally,xaxchestxtubexisxnotxclampedx
unlessxthisxhasxbeenxspecificallyxprescribedxinxthexagency’sxpoliciesxandxpr
ocedures.xChangingxthexdrainagexsystemxwillxnotxalleviatexthexproblem.xRe
ducingxthexdegreexofxsuctionxbeingxappliedxwillxnotxaffectxthexbubblingxinxt
hexwaterxsealxchamberxandxcouldxbexharmful.xThexnursexwouldxdocumentxt
hexassessmentxfindingsxandxinterventionsxtakenxinxthexclient’sxmedicalxreco
rd.
Test-TakingxStrategy:xFocusxonxthexdataxinxthexquestion,xnotingxthatxtherexi
sxbubblingxinxthexwaterxsealxchamber.xUsexknowledgexregardingxthexpriorityx
actionsxinxthexcarexofxaxclosedxchestxtubexdrainagexsystem.xRecallingxthatxthi
sxmayxindicatexanxairxleakxwillxdirectxyouxtoxthexcorrectxoptions.xReviewxthex
nursingxactionsxtoxbextakenximmediatelyxinxthexeventxthatxcomplicationsxofxax
closedxchestxtubexdrainagexsystemxoccur
LevelxofxCognitivexAbility:xApplying
ClientxNeeds:xPhysiologicalxIntegrity
IntegratedxProcess:xNursingxProcess/Implementation
ContentxArea:
CriticalxCare:xEmergencyx Situation/Management
GiddensxConcepts:xCarexCoordination,xGasxExchange
HESIxConcepts:x NursingxInterventions,x Oxygenation/GasxExchange
Reference:xLewis,xS.,xDirksen,xS.,xHeitkemper,xM.,x&xBucher,xL.x(2014).x
Medical-surgicalxnursing:xAssessmentxandxmanagementxofxclinicalxproble
msx(9thxxed.,xp.x546).xSt.xLouis:xMosby.
Awardedx2.0xpointsxoutxofx2.0xpossiblexpoints.
5. 5.ID:x9477055619
Axnursexisxhelpingxaxclientxwithxaxclosedxchestxtubexdrainagexsystemxgetxout
xofxbedxandxintoxaxchair.xDuringxthextransfer,xthexchestxtubexisxcaughtxonxthe
xlegxofxthexchairxandxdislodgedxfromxthexinsertionxsite.xWhatxisxtheximmediat
exnursingxaction?
A. Reinsertxthexchestxtube
