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Saunders NCLEX Questions and Answers (2023/2024) (Verified Answers)
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Saunders NCLEX Questions and Answers (2023/2024) (Verified Answers)
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Saunders NCLEX questions1. The nurse is assessing a client's postoperative pain using the PQRSTU
method. Using this method, which questions would the nurse ask the
client?: The PQRSTU method is one method of assessing pain. With this
method, the nurse asks about the following: Precipitating factors (option 6);
Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity
of the pain; Timing of the pain (continuous or intermittent); and How the pain
affects you (option 4). Options 2 and 5 may be questions that would be asked;
however, these are not a part of the PQRSTU method.
2. The nurse is preparing to administer furosemide (Lasix) to a client with
a diagnosis of heart failure. Which is the most important laboratory test
result for the nurse to check before administering this medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level: Furosemide is a loop diuretic. The medication causes a
decrease in the client's electrolytes, especially potassium, sodium, and chloride.
Administering furosemide to a client with low electrolyte levels could precipitate
ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol
level is unrelated to the administration of this medication.
3. A nurse caring for a client with a diagnosis of gastrointestinal (GI)
bleeding reviews the client's laboratory results and notes a hematocrit level
of 30%. Which action should the nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record.: 1-Report the
abnormally low level.
The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 %
in a female, depending on age. A hematocrit level of 30% is a low level and would
be reported to the health care provider because it indicates blood loss; therefore
options 2, 3, and 4 are incorrect.
4. A nurse provides dietary instructions to a client who will be taking
warfarin sodium (Coumadin). The nurse should tell the client to avoid which
food item?
, Saunders NCLEX questions
1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese: 2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act by
antagonizing the action of vitamin K, which is needed for clotting. When a client is
taking an anticoagulant, foods high in vitamin K often are omitted from the diet.
Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee, and tea.
5. A client who has been receiving total parenteral nutrition (TPN) by way
of a central venous access device complains of chest pain and dyspnea.
The nurse quickly assesses the client's vital signs and notes that the pulse
rate has increased and the blood pressure has dropped. The nurse
determines that the client is most likely experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance: 2-Air embolism
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia,
anxiety, tachycardia, and hypotension. The nurse also may hear a loud churning
sound over the pericardium on auscultation of the client's chest. The signs and
symptoms of sepsis include fever, chills, and general malaise. Fluid overload
causes increased intravascular volume, which increases the blood pressure and
the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also
causes neck vein distention and shifting of fluid into the alveoli, resulting in lung
crackles. The signs and symptoms of a fluid imbalance depend on the type of
imbalance the client is experiencing.
6. A client who is receiving intravenous (IV) fluid therapy complains of
burning and a feeling of tightness at the IV insertion site. On assessment,
the nurse detects coolness and swelling at the site and notes that the IV
rate has slowed. The nurse determines that which complication has
occurred?: 1-Infection 2-Phlebitis
3-Infiltration
4-Thrombosis
, Saunders NCLEX questions
An infiltrated IV line is one that has dislodged from the vein and is lying in
subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV
fluid is deposited in the subcutaneous tissue. When the pressure in the tissues
exceeds the pressure in the tubing, the flow of IV solution will slow down or stop.
The corrective action is to remove the catheter and start a new IV line at another
site. The conditions identified in options 1, 2, and 4 are likely to be accompanied
by warmth at the site, not coolness.
7. A nurse provides instructions to a preoperative client about the use of
an incentive spirometer. The nurse determines that the client needs further
instruction if the client indicates that he or she will take which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale.:
4-After maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume
a semi-Fowler's or high Fowler's position. The mouthpiece should be covered
completely and tightly while the client inhales slowly, with a constant flow through
the unit. When maximal inspiration is reached, the client should hold the breath for
2 or
3 seconds and then exhale slowly
8. The nurse is monitoring a client who has a closed chest tube drainage
system. The nurse notes fluctuation of the fluid level in the water-seal
chamber during inspiration and expiration. On the basis of this finding, the
nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement.: 2-The
chest tube is functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a
patent drainage system. With normal breathing, the water level rises with
inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if
, Saunders NCLEX questions
the suction is not working properly, or if the lung has re-expanded. Options 1, 3,
and 4 are incorrect interpretations of the finding. An air leak may cause excessive
bubbling in the water seal chamber. Excessive and vigorous bubbling in the
suction control chamber may indicate that the amount of suction needs to be
decreased. The status of the dressing is not specifically related to the presence of
fluctuation of the fluid level in the water-seal chamber
9. A nurse is providing morning care to a client who has a closed chest tube
drainage system to treat a pneumothorax. When the nurse turns the client to
the side, the chest tube is accidentally dislodged from the chest. The nurse
immediately applies sterile gauze over the chest tube insertion site. Which is
the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position: 1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse
immediately applies sterile gauze over the site and calls the health care provider.
The nurse would maintain the client in an upright position. A new chest tube
system may be attached if the tube requires insertion, but this would not be the
next action. Pulse oximetry readings would assist in determining the client's
respiratory status, but the priority action would be to call the health care provider
in this emergency situation. 10. A nurse reviews the medication history of a
client and notes that the client is taking leflunomide (Arava). During
assessment of the client, the nurse should ask which question to determine
the effectiveness of this medication?
1-"Do you have any joint pain?"
2-"Are you having any diarrhea?"
3-"Are you experiencing heartburn?"
4-"Do you have frequent headaches?": 1-"Do you have any joint pain?"
Leflunomide is an immunomodulatory agent and has an anti-inflammatory action.
The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can
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