NCLEX RN ACTUAL EXAM TEST BANK WITH REAL AND EXACT EXAM
QUESTIONS & ANSWERS NCLEX 2025/2026 NCLEX EXAM 860+ Q&A
QUESTION 1
A nurse is assessing a client who is 24 hours post-operative following a right total
knee arthroplasty. Which of the following findings requires immediate
intervention?
A. Pain rating of 6 on a 0–10 scale
B. Temperature of 99.8°F (37.7°C)
C. Right calf circumference 3 cm larger than left
D. Serosanguineous drainage on the dressing
Correct Answer: C
Explanation:
A unilateral increase in calf circumference suggests possible deep vein
thrombosis (DVT), a serious complication following joint replacement surgery. This
requires immediate intervention with ultrasound confirmation and anticoagulation.
Pain is expected post-operatively. Low-grade fever is common after surgery.
Serosanguineous drainage is expected.
QUESTION 2
A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 86% on room air. The nurse applies supplemental oxygen at 2 L/min
via nasal cannula. Which of the following findings would indicate an adverse
reaction to oxygen therapy in this client?
,A. Respiratory rate increase from 22 to 26 breaths per minute
B. Oxygen saturation increase to 92%
C. Client reports decreased headache
D. Respiratory rate decrease from 24 to 12 breaths per minute
Correct Answer: D
Explanation:
Clients with COPD may have chronic hypercapnia and rely on hypoxic drive to
stimulate breathing. Excessive oxygen can decrease the hypoxic drive, leading to
respiratory depression. A decrease in respiratory rate to 12 breaths per minute
indicates respiratory depression, which is an adverse reaction. The other options
indicate appropriate response to therapy.
QUESTION 3
A nurse is providing discharge teaching to a client with heart failure. Which of the
following statements by the client indicates understanding of the teaching?
A. "I will weigh myself every morning after breakfast."
B. "I should limit my fluid intake to 3 liters per day."
C. "I will notify my doctor if I gain more than 2 pounds in 24 hours."
D. "I can stop taking my diuretic if I feel short of breath."
Correct Answer: C
Explanation:
A weight gain of 2–3 pounds in 24 hours or 5 pounds in one week indicates fluid
retention and worsening heart failure, requiring provider notification. Weighing
should be done daily in the morning, after voiding, before breakfast. Fluid
,restriction is typically 1.5–2 L/day, not 3 L. Diuretics should never be stopped
without provider instruction.
QUESTION 4
A client is admitted with a diagnosis of acute appendicitis. Which of the following
assessment findings would the nurse expect?
A. Rebound tenderness at McBurney's point
B. Generalized abdominal pain that is constant
C. Pain that decreases with movement
D. Constipation for the past 3 days
Correct Answer: A
Explanation:
Acute appendicitis typically presents with rebound tenderness and localized pain
at McBurney's point (one-third the distance from the anterior superior iliac spine
to the umbilicus). Pain is initially periumbilical then localizes to the right lower
quadrant. Pain increases with movement. Diarrhea or constipation may occur but
is not the classic finding.
QUESTION 5
A nurse is caring for a client receiving total parenteral nutrition (TPN) through a
central line. Which of the following actions is most important?
A. Change the IV tubing every 24 hours
B. Monitor blood glucose levels every 6 hours
, C. Weigh the client daily
D. Check the insertion site for redness and drainage
Correct Answer: A
Explanation:
TPN is a hypertonic solution with high glucose content that supports bacterial
growth. IV tubing must be changed every 24 hours to prevent catheter-related
bloodstream infections, which are the most serious complication. Blood glucose
monitoring, daily weights, and site assessment are important but secondary to
infection prevention.
QUESTION 6
A client with bipolar disorder is in the manic phase. Which of the following nursing
interventions is most appropriate?
A. Place the client in a room with a highly active roommate
B. Provide detailed, complex instructions for activities
C. Offer high-calorie finger foods frequently
D. Confront the client about grandiose statements
Correct Answer: C
Explanation:
During manic episodes, clients are hyperactive and often unable to sit for meals.
Offering high-calorie finger foods that can be eaten while moving helps maintain
nutrition. The client should be in a quiet, low-stimulation environment, not with an
active roommate. Instructions should be simple and brief. Confrontation increases
agitation.
QUESTIONS & ANSWERS NCLEX 2025/2026 NCLEX EXAM 860+ Q&A
QUESTION 1
A nurse is assessing a client who is 24 hours post-operative following a right total
knee arthroplasty. Which of the following findings requires immediate
intervention?
A. Pain rating of 6 on a 0–10 scale
B. Temperature of 99.8°F (37.7°C)
C. Right calf circumference 3 cm larger than left
D. Serosanguineous drainage on the dressing
Correct Answer: C
Explanation:
A unilateral increase in calf circumference suggests possible deep vein
thrombosis (DVT), a serious complication following joint replacement surgery. This
requires immediate intervention with ultrasound confirmation and anticoagulation.
Pain is expected post-operatively. Low-grade fever is common after surgery.
Serosanguineous drainage is expected.
QUESTION 2
A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 86% on room air. The nurse applies supplemental oxygen at 2 L/min
via nasal cannula. Which of the following findings would indicate an adverse
reaction to oxygen therapy in this client?
,A. Respiratory rate increase from 22 to 26 breaths per minute
B. Oxygen saturation increase to 92%
C. Client reports decreased headache
D. Respiratory rate decrease from 24 to 12 breaths per minute
Correct Answer: D
Explanation:
Clients with COPD may have chronic hypercapnia and rely on hypoxic drive to
stimulate breathing. Excessive oxygen can decrease the hypoxic drive, leading to
respiratory depression. A decrease in respiratory rate to 12 breaths per minute
indicates respiratory depression, which is an adverse reaction. The other options
indicate appropriate response to therapy.
QUESTION 3
A nurse is providing discharge teaching to a client with heart failure. Which of the
following statements by the client indicates understanding of the teaching?
A. "I will weigh myself every morning after breakfast."
B. "I should limit my fluid intake to 3 liters per day."
C. "I will notify my doctor if I gain more than 2 pounds in 24 hours."
D. "I can stop taking my diuretic if I feel short of breath."
Correct Answer: C
Explanation:
A weight gain of 2–3 pounds in 24 hours or 5 pounds in one week indicates fluid
retention and worsening heart failure, requiring provider notification. Weighing
should be done daily in the morning, after voiding, before breakfast. Fluid
,restriction is typically 1.5–2 L/day, not 3 L. Diuretics should never be stopped
without provider instruction.
QUESTION 4
A client is admitted with a diagnosis of acute appendicitis. Which of the following
assessment findings would the nurse expect?
A. Rebound tenderness at McBurney's point
B. Generalized abdominal pain that is constant
C. Pain that decreases with movement
D. Constipation for the past 3 days
Correct Answer: A
Explanation:
Acute appendicitis typically presents with rebound tenderness and localized pain
at McBurney's point (one-third the distance from the anterior superior iliac spine
to the umbilicus). Pain is initially periumbilical then localizes to the right lower
quadrant. Pain increases with movement. Diarrhea or constipation may occur but
is not the classic finding.
QUESTION 5
A nurse is caring for a client receiving total parenteral nutrition (TPN) through a
central line. Which of the following actions is most important?
A. Change the IV tubing every 24 hours
B. Monitor blood glucose levels every 6 hours
, C. Weigh the client daily
D. Check the insertion site for redness and drainage
Correct Answer: A
Explanation:
TPN is a hypertonic solution with high glucose content that supports bacterial
growth. IV tubing must be changed every 24 hours to prevent catheter-related
bloodstream infections, which are the most serious complication. Blood glucose
monitoring, daily weights, and site assessment are important but secondary to
infection prevention.
QUESTION 6
A client with bipolar disorder is in the manic phase. Which of the following nursing
interventions is most appropriate?
A. Place the client in a room with a highly active roommate
B. Provide detailed, complex instructions for activities
C. Offer high-calorie finger foods frequently
D. Confront the client about grandiose statements
Correct Answer: C
Explanation:
During manic episodes, clients are hyperactive and often unable to sit for meals.
Offering high-calorie finger foods that can be eaten while moving helps maintain
nutrition. The client should be in a quiet, low-stimulation environment, not with an
active roommate. Instructions should be simple and brief. Confrontation increases
agitation.
