NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
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
Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence
occurs, the nurse immediately places the client in a low Fowler’s position or supine with the knees
bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying
tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The
NURSING NCLEX EXAM QUESTIONS AND ANSWERS
health care provider is notified, and the nurse documents the occurrence and the nursing actions
100%CORRECT/VERIFIED BEST RATED A+
that were implemented in response.
Test-Taking Strategy: Note the strategic word “immediate.” Visualize this occurrence and recall that
GUARANTEED SUCCESS NEW UPDATE 2022
the primary concern when wound dehiscence occurs is the protrusion of underlying tissues. This will
direct you to the correct option. Review the nursing actions to be taken immediately in the event of
wound dehiscence
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
,NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
Giddens Concepts: Caregiving, Tissue Integrity
HESI Concepts: Caregiving, Tissue Integrity
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
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.
NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
,NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477051455
A client who has just undergone surgery suddenly experiences chest pain,
dyspnea, and tachypnea. The nurse suspects that the client has a
pulmonary embolism and immediately sets about to take which action?
A. Preparing the client for a perfusion scan
B. Attaching the client to a cardiac monitor
C. Administering oxygen by way of nasal cannula Correct
D. Ensuring that the intravenous (IV) line is patent
NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
, NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
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.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477051498
A nurse is assessing a client who has a closed chest tube drainage
system. The nurse notes constant bubbling in the water seal chamber.
What actions should the nurse take? (Select all that apply).
A. Clamp the chest tube
B. Chang the drainage system
C. Assess the system for an external air leak Correct
D. Reduce the degree of suction being applied
E. Document assessment findings, actions taken, and
client response Correct
NURSING NCLEX EXAM QUESTIONS AND ANSWERS
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
100%CORRECT/VERIFIED
of an external air leak if constant bubbling were BEST RATED
noted in this A+
chamber. If an external air leak is not
present and the air leak is a new occurrence, the health care provider is notified immediately,
GUARANTEED SUCCESS NEW UPDATE 2022
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
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
Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence
occurs, the nurse immediately places the client in a low Fowler’s position or supine with the knees
bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying
tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The
NURSING NCLEX EXAM QUESTIONS AND ANSWERS
health care provider is notified, and the nurse documents the occurrence and the nursing actions
100%CORRECT/VERIFIED BEST RATED A+
that were implemented in response.
Test-Taking Strategy: Note the strategic word “immediate.” Visualize this occurrence and recall that
GUARANTEED SUCCESS NEW UPDATE 2022
the primary concern when wound dehiscence occurs is the protrusion of underlying tissues. This will
direct you to the correct option. Review the nursing actions to be taken immediately in the event of
wound dehiscence
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
,NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
Giddens Concepts: Caregiving, Tissue Integrity
HESI Concepts: Caregiving, Tissue Integrity
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
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.
NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
,NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477051455
A client who has just undergone surgery suddenly experiences chest pain,
dyspnea, and tachypnea. The nurse suspects that the client has a
pulmonary embolism and immediately sets about to take which action?
A. Preparing the client for a perfusion scan
B. Attaching the client to a cardiac monitor
C. Administering oxygen by way of nasal cannula Correct
D. Ensuring that the intravenous (IV) line is patent
NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
, NURSING NCLEX EXAM QUESTIONS AND ANSWERS
100%CORRECT/VERIFIED BEST RATED A+
GUARANTEED SUCCESS NEW UPDATE 2022
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.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477051498
A nurse is assessing a client who has a closed chest tube drainage
system. The nurse notes constant bubbling in the water seal chamber.
What actions should the nurse take? (Select all that apply).
A. Clamp the chest tube
B. Chang the drainage system
C. Assess the system for an external air leak Correct
D. Reduce the degree of suction being applied
E. Document assessment findings, actions taken, and
client response Correct
NURSING NCLEX EXAM QUESTIONS AND ANSWERS
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
100%CORRECT/VERIFIED
of an external air leak if constant bubbling were BEST RATED
noted in this A+
chamber. If an external air leak is not
present and the air leak is a new occurrence, the health care provider is notified immediately,
GUARANTEED SUCCESS NEW UPDATE 2022
