NCLEX Questions 4100 exam 1 Latest Update
2025-2026 Questions and 100% Verified Correct
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A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is
being assessed by the nurse. Which assessment findings would be consistent with
acute pancreatitis? Select all that apply.
1.Diarrhea
2.Black, tarry stools
3.Hyperactive bowel sounds
4.Gray-blue color at the flank
5.Abdominal guarding and tenderness 6.Left upper quadrant pain with radiation to the
back - CORRECT ANSWER: 4, 5, 6
Rationale:Grayish-blue discoloration at the flank is known as Grey-Turner's sign and
occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal
cavity. The client may demonstrate abdominal guarding and may complain of
tenderness with palpation. The pain associated with acute pancreatitis is often sudden
in onset and is located in the epigastric region or left upper quadrant with radiation to
the back. The other options are incorrect.
A client being discharged home after renal transplantation has a risk for infection related
to immunosuppressive medication therapy. The nurse determines that the client needs
further teaching on measures to prevent and control infection if the client states that it is
necessary to take which action?
1.Take an oral temperature daily.
2.Use good hand-washing technique.
3.Take all scheduled medications exactly as prescribed.
,4.Monitor urine character and output at least 1 day each week. - CORRECT ANSWER:
4
Rationale:The client receiving immunosuppressive medication therapy must learn and
use infection control methods for use at home. The client self-monitors urine output and
its characteristics on a daily basis. The client must learn proper hand-washing technique
and should take the temperature daily to detect early infection. This is especially
important because the client also takes corticosteroids, which mask signs and
symptoms of infection. All medications should be taken exactly as prescribed.
A client experiencing end-stage kidney disease has an arteriovenous (AV) fistula placed
surgically for hemodialysis. Which action is most appropriate for the nurse to document
in the plan for care of the AV fistula?
1.Palpate the bruit of the AV fistula weekly to assess for thrombosis.
2.Use the AV fistula site for blood draws to prevent increased pain of multiple blood
draws.
3.Take the blood pressure readings in the extremity with the AV fistula to get a more
accurate reading.
4.Teach the client to avoid carrying heavy objects that would compress the AV fistula
and cause thrombosis. - CORRECT ANSWER: 4
Rationale:An AV fistula is a vascular access system that is required for hemodialysis. It
is a device established for clients who need long-term hemodialysis. It is created by
connecting an artery to a vein inside the body to create a vessel that can handle the
amount of blood flow necessary for effective dialysis. Bleeding, clotting, and infection
are risks with all vascular devices. It also is very important to avoid any activity that
would promote the status of blood or increase the risk for infection. Taking the blood
pressure in the affected arm, carrying heavy objects in the arm, and lying on the arm at
night could increase the risk for clotting in the fistula. To check circulation of the fistula,
the nurse should palpate or feel for the thrill or auscultate (listen with a stethoscope) for
the bruit. It is important to do this at least daily to ascertain the patency of the fistula. To
avoid infection, that extremity is never used for peripheral intravenous access
(placement of an intravenous line) or for blood draws. Strict aseptic technique is used in
accessing the fistula for dialysis.
,A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would
the nurse expect the client to report about the pain?
1.Eating helps to decrease the pain.
2.The pain usually increases after vomiting.
3.The pain is mostly around the umbilicus and comes and goes.
4.The pain increases when the client sits up and bends forward. - CORRECT ANSWER:
2
Rationale:Pain with acute pancreatitis usually increases after vomiting because of an
increase in intraductal pressure caused by retching, which leads to further obstruction of
the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain
that radiates to the client's back and flank. The pain may lessen when the client sits up
or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.
A client is admitted to the hospital with suspected bladder cancer. The nurse assesses
the client for which early signs and symptoms of the disease?
1.Proteinuria and dysuria
2.Hematuria and absence of pain
3.Painful urination and hematuria
4.Pyuria and palpable abdominal mass - CORRECT ANSWER: 2
Rationale:The most common earliest manifestation of bladder cancer is hematuria that
is not accompanied by pain. The hematuria is intermittent at first. Later signs and
symptoms include hematuria with dysuria and frequency because of bladder irritation.
Pyuria and proteinuria are not part of the clinical picture. A mass usually is not palpable.
A client is being evaluated as a potential kidney donor for a family member. The client
asks the nurse why separate teams are evaluating donor and recipient. What is the
most appropriate response by the nurse?
1.Helps reduce the cost of the preoperative workup
, 2.Saves the client and the recipient valuable preoperative time
3.Avoids a conflict of interest between the team evaluating the recipient and the team
evaluating the donor
4.Provides for a sufficient number of persons reviewing the case so that no information
is overlooked - CORRECT ANSWER: 3
Rationale:Both the kidney donor and the kidney recipient need thorough medical and
psychological evaluation before transplant surgery. Separate teams evaluate the donor
and the recipient to avoid a conflict of interest in providing care for the 2 clients. Options
1, 2, and 4 are not related to the purpose of this approach.
A client is having difficulty coughing and deep-breathing because of pain after a
nephrectomy. Which action by the nurse is helpful in promoting optimal respiratory
function?
1.Administering pain medication just before ambulation
2.Administering pain medication when the client asks for it
3.Encouraging the use of the incentive spirometer every 8 hours
4.Assisting the client to splint the incision during respiratory exercise - CORRECT
ANSWER: 4
Rationale:The client who has had a nephrectomy may have pain with coughing and
deep breathing and other respiratory exercises because the location of the incision is so
close to the diaphragm. The nurse assists the client by offering opioid analgesics when
due, encouraging incentive spirometer use hourly, and assisting the client to splint the
incision during coughing. If the client takes pain medication only before ambulation,
control of pain may be insufficient, which will not promote optimal respiratory function
(pain medication should be offered 30 to 45 minutes before the client ambulates).
Laparoscopic nephrectomy can also be performed. Compared to conventional
nephrectomy, the laparoscopic approach is less painful and requires no sutures or
staples, involves a shorter hospital stay, and has a much faster recovery.
A client presents to the emergency department with upper gastrointestinal (GI) bleeding
and is in moderate distress. In planning care, which nursing action should be the priority
for this client?
2025-2026 Questions and 100% Verified Correct
Answers Guaranteed A+
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is
being assessed by the nurse. Which assessment findings would be consistent with
acute pancreatitis? Select all that apply.
1.Diarrhea
2.Black, tarry stools
3.Hyperactive bowel sounds
4.Gray-blue color at the flank
5.Abdominal guarding and tenderness 6.Left upper quadrant pain with radiation to the
back - CORRECT ANSWER: 4, 5, 6
Rationale:Grayish-blue discoloration at the flank is known as Grey-Turner's sign and
occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal
cavity. The client may demonstrate abdominal guarding and may complain of
tenderness with palpation. The pain associated with acute pancreatitis is often sudden
in onset and is located in the epigastric region or left upper quadrant with radiation to
the back. The other options are incorrect.
A client being discharged home after renal transplantation has a risk for infection related
to immunosuppressive medication therapy. The nurse determines that the client needs
further teaching on measures to prevent and control infection if the client states that it is
necessary to take which action?
1.Take an oral temperature daily.
2.Use good hand-washing technique.
3.Take all scheduled medications exactly as prescribed.
,4.Monitor urine character and output at least 1 day each week. - CORRECT ANSWER:
4
Rationale:The client receiving immunosuppressive medication therapy must learn and
use infection control methods for use at home. The client self-monitors urine output and
its characteristics on a daily basis. The client must learn proper hand-washing technique
and should take the temperature daily to detect early infection. This is especially
important because the client also takes corticosteroids, which mask signs and
symptoms of infection. All medications should be taken exactly as prescribed.
A client experiencing end-stage kidney disease has an arteriovenous (AV) fistula placed
surgically for hemodialysis. Which action is most appropriate for the nurse to document
in the plan for care of the AV fistula?
1.Palpate the bruit of the AV fistula weekly to assess for thrombosis.
2.Use the AV fistula site for blood draws to prevent increased pain of multiple blood
draws.
3.Take the blood pressure readings in the extremity with the AV fistula to get a more
accurate reading.
4.Teach the client to avoid carrying heavy objects that would compress the AV fistula
and cause thrombosis. - CORRECT ANSWER: 4
Rationale:An AV fistula is a vascular access system that is required for hemodialysis. It
is a device established for clients who need long-term hemodialysis. It is created by
connecting an artery to a vein inside the body to create a vessel that can handle the
amount of blood flow necessary for effective dialysis. Bleeding, clotting, and infection
are risks with all vascular devices. It also is very important to avoid any activity that
would promote the status of blood or increase the risk for infection. Taking the blood
pressure in the affected arm, carrying heavy objects in the arm, and lying on the arm at
night could increase the risk for clotting in the fistula. To check circulation of the fistula,
the nurse should palpate or feel for the thrill or auscultate (listen with a stethoscope) for
the bruit. It is important to do this at least daily to ascertain the patency of the fistula. To
avoid infection, that extremity is never used for peripheral intravenous access
(placement of an intravenous line) or for blood draws. Strict aseptic technique is used in
accessing the fistula for dialysis.
,A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would
the nurse expect the client to report about the pain?
1.Eating helps to decrease the pain.
2.The pain usually increases after vomiting.
3.The pain is mostly around the umbilicus and comes and goes.
4.The pain increases when the client sits up and bends forward. - CORRECT ANSWER:
2
Rationale:Pain with acute pancreatitis usually increases after vomiting because of an
increase in intraductal pressure caused by retching, which leads to further obstruction of
the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain
that radiates to the client's back and flank. The pain may lessen when the client sits up
or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.
A client is admitted to the hospital with suspected bladder cancer. The nurse assesses
the client for which early signs and symptoms of the disease?
1.Proteinuria and dysuria
2.Hematuria and absence of pain
3.Painful urination and hematuria
4.Pyuria and palpable abdominal mass - CORRECT ANSWER: 2
Rationale:The most common earliest manifestation of bladder cancer is hematuria that
is not accompanied by pain. The hematuria is intermittent at first. Later signs and
symptoms include hematuria with dysuria and frequency because of bladder irritation.
Pyuria and proteinuria are not part of the clinical picture. A mass usually is not palpable.
A client is being evaluated as a potential kidney donor for a family member. The client
asks the nurse why separate teams are evaluating donor and recipient. What is the
most appropriate response by the nurse?
1.Helps reduce the cost of the preoperative workup
, 2.Saves the client and the recipient valuable preoperative time
3.Avoids a conflict of interest between the team evaluating the recipient and the team
evaluating the donor
4.Provides for a sufficient number of persons reviewing the case so that no information
is overlooked - CORRECT ANSWER: 3
Rationale:Both the kidney donor and the kidney recipient need thorough medical and
psychological evaluation before transplant surgery. Separate teams evaluate the donor
and the recipient to avoid a conflict of interest in providing care for the 2 clients. Options
1, 2, and 4 are not related to the purpose of this approach.
A client is having difficulty coughing and deep-breathing because of pain after a
nephrectomy. Which action by the nurse is helpful in promoting optimal respiratory
function?
1.Administering pain medication just before ambulation
2.Administering pain medication when the client asks for it
3.Encouraging the use of the incentive spirometer every 8 hours
4.Assisting the client to splint the incision during respiratory exercise - CORRECT
ANSWER: 4
Rationale:The client who has had a nephrectomy may have pain with coughing and
deep breathing and other respiratory exercises because the location of the incision is so
close to the diaphragm. The nurse assists the client by offering opioid analgesics when
due, encouraging incentive spirometer use hourly, and assisting the client to splint the
incision during coughing. If the client takes pain medication only before ambulation,
control of pain may be insufficient, which will not promote optimal respiratory function
(pain medication should be offered 30 to 45 minutes before the client ambulates).
Laparoscopic nephrectomy can also be performed. Compared to conventional
nephrectomy, the laparoscopic approach is less painful and requires no sutures or
staples, involves a shorter hospital stay, and has a much faster recovery.
A client presents to the emergency department with upper gastrointestinal (GI) bleeding
and is in moderate distress. In planning care, which nursing action should be the priority
for this client?
