SAUNDERS ACTUAL EXAM PAPER WITH
VERIFIED QUESTIONS AND GRADED A PLUS
ANSWERS 2026
‣ The nurse is assessing a client's postoperative pain using the PQRSTU
method. Using this method, which questions would the nurse ask the
client? Answer: 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.
‣ 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 . Answer: 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.
,‣ 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. . Answer: 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.
‣ 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?
1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese . Answer: 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.
‣ 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 . Answer: 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.
, ‣ 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? . Answer: 1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
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.
‣ 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.
VERIFIED QUESTIONS AND GRADED A PLUS
ANSWERS 2026
‣ The nurse is assessing a client's postoperative pain using the PQRSTU
method. Using this method, which questions would the nurse ask the
client? Answer: 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.
‣ 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 . Answer: 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.
,‣ 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. . Answer: 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.
‣ 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?
1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese . Answer: 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.
‣ 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 . Answer: 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.
, ‣ 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? . Answer: 1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
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.
‣ 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.
