NCLEXVault 2026From pre-nursing to NCLEX-ready

Answer: Increase oxygen according to the emergency protocol and position the client upright.

Severe hypoxemia, inability to speak, retractions, and acute confusion indicate immediate respiratory compromise. Support oxygenation and ventilation first while escalating care. Medication history and coached breathing may follow stabilization; supine positioning and a fluid bolus can worsen pulmonary congestion.

Study tip: When several cues point to failing oxygenation, intervene for airway and breathing before completing routine assessment tasks.

Answer: Escalate care, obtain cultures, begin isotonic fluid resuscitation, and trend perfusion and urine output.

Hypotension, oliguria, tachypnea, altered mentation, and lactate above 4 mmol/L indicate sepsis with impaired perfusion. Cultures should be collected promptly without delaying prescribed broad-spectrum antibiotics. Fluids and frequent perfusion reassessment are time-sensitive; fever is not a reason to delay treatment.

Study tip: Read vital signs as a trend. Falling pressure plus altered mentation, oliguria, and elevated lactate signals shock even before a diagnosis is stated.

Answer: Discontinue the insulin infusion because glucose is below 200 mg/dL.

The glucose has improved, but acidosis and the elevated anion gap have not resolved. Dextrose is added so insulin can continue clearing ketones. Potassium of 3.2 mEq/L requires replacement and may require a temporary insulin pause because insulin shifts potassium intracellularly.

Study tip: In DKA, glucose normalizes before ketoacidosis. Follow the anion gap and bicarbonate, not glucose alone, when deciding whether insulin can stop.

Answer: Confirm last-known-well time, keep NPO, manage blood pressure per protocol, and repeat neurologic and blood-pressure assessments.

Time of onset determines eligibility, dysphagia creates aspiration risk, and blood pressure must meet the treatment threshold before thrombolysis. Frequent reassessment detects deterioration. Aspirin is withheld until hemorrhage and thrombolytic decisions are addressed; the weak extremity requires supported positioning.

Study tip: For suspected stroke, protect time, airway, and eligibility: last known well, glucose, CT, swallow safety, and controlled blood pressure.

Answer: Massage the fundus while calling for assistance.

A boggy, displaced fundus with heavy bleeding suggests uterine atony worsened by bladder distention. Immediate fundal massage promotes contraction while help, bladder emptying, uterotonics, IV access, and hemorrhage protocols are initiated.

Study tip: Boggy fundus means atony: massage first. A fundus shifted right also points to a full bladder that must be emptied.

Answer: Continuous monitoring, IV calcium, insulin with dextrose, and preparation for potassium removal.

ECG changes make this a cardiac emergency. Calcium stabilizes the myocardium, insulin with dextrose shifts potassium into cells, and definitive removal may require a potassium binder, diuretic, or dialysis depending on kidney function and response.

Study tip: Treat hyperkalemia in three steps: protect the heart, shift potassium into cells, then remove potassium from the body.

Answer: The client with stable COPD receiving scheduled nebulizer treatments.

The LPN/LVN cares for clients whose condition is stable and whose outcomes are predictable. New-onset chest pain and the immediate post-thyroidectomy client are unstable and need registered-nurse assessment; initial teaching about a new device must be initiated by the RN, although the LPN/LVN may reinforce it afterwards.

Study tip: Stable + predictable = LPN. New, unstable, or first-time teaching = RN.

Answer: Vital signs, assisted ambulation, intake and output, and a bed bath.

Unlicensed assistive personnel may perform standard, unchanging tasks on stable clients. Reinforcing teaching requires a licensed nurse, and evaluating the effect of a medication is nursing judgement that cannot be assigned.

Study tip: If the task needs teaching, judgement, or evaluation, it cannot go to a UAP.

Answer: Apical pulse of 52 beats per minute.

Digoxin slows conduction, and an apical rate below 60 beats per minute in an adult is the standard parameter for holding the dose and reporting. The blood pressure and potassium are within expected limits; a different-looking tablet should be verified but is not the priority hold parameter.

Study tip: Count the apical pulse for a full minute before every digoxin dose.