Test Bank for Saunders Comprehensive Review for the NCLEX-
RN® Examination, 9th Edition by Linda Anne Silvestri and Angela
Silvestri – Complete Questions and Answers (Pass Guaranteed)
|| Updated 2026 (strictly 100-150pages)
Fundamentals NCLEX Q&A With Rationales
1. The nurse is obtaining vital signs for an adult client. Which finding
requires immediate follow-up?
A. Respiratory rate 18 breaths/min
B. Blood pressure 118/76 mm Hg
C. Heart rate 124 beats/min
D. Oral temperature 37.2°C (99°F)
Answer: C
Rationale: A heart rate of 124 beats/min is tachycardia and may
indicate pain, anxiety, hypovolemia, or other acute problems that
require prompt assessment; the other values are within expected
ranges.
1. A nurse is preparing to administer morning medications. Which
action is the highest priority?
A. Explaining each medication to the client
B. Checking the client’s identification using two identifiers
C. Asking the client about food preferences
D. Documenting the medications to be given
,Answer: B
Rationale: Verifying the correct client using two identifiers is a core
patient-safety step and must occur before giving any medication to
prevent errors.
1. The nurse is reinforcing fire safety on a hospital unit. Which action
follows the RACE acronym correctly as the first step?
A. Close all doors to client rooms
B. Report the fire to the operator
C. Rescue clients in immediate danger
D. Extinguish the fire using the nearest extinguisher
Answer: C
Rationale: RACE stands for Rescue, Alarm, Contain, Extinguish; the first
priority is rescuing anyone in immediate danger before sounding the
alarm or attempting to extinguish the fire.
1. The nurse is caring for a client on contact precautions for
Clostridioides difficile infection. Which action is most appropriate?
A. Use an alcohol-based hand rub after removing gloves
B. Wear a surgical mask for all client contact
C. Wash hands with soap and water after removing gloves
D. Place the client in a negative-pressure room
Answer: C
Rationale: C. difficile forms spores that are not reliably removed by
alcohol; handwashing with soap and water is required after glove
removal to prevent transmission.
, 1. A client with limited English proficiency nods and says “yes” after
discharge teaching. The nurse suspects the client may not fully
understand. What is the best action?
A. Provide written instructions and ask the client to read them
later
B. Ask the family to explain the discharge instructions
C. Ask the client to repeat the information back in their own words
D. Continue with the next topic to avoid embarrassing the client
Answer: C
Rationale: The teach-back method (having the client restate
information) verifies understanding and allows the nurse to correct or
clarify any misunderstandings immediately.
1. The nurse is preparing to perform hand hygiene before a sterile
procedure. Which situation requires washing with soap and water
instead of alcohol-based hand rub?
A. Hands are visibly soiled
B. Before entering a client’s room
C. After removing clean gloves
D. After taking the client’s blood pressure
Answer: A
Rationale: Alcohol-based hand rub is appropriate when hands are not
visibly soiled; visible dirt or organic material requires washing with soap
and water.
, 1. The nurse is assisting a client to ambulate with a cane. Which
instruction is correct?
A. “Hold the cane on the weaker side.”
B. “Move the cane and weaker leg forward together.”
C. “Look at your feet while walking.”
D. “Place the cane 30–40 cm (12–16 in) in front of you.”
Answer: B
Rationale: The client should hold the cane on the stronger side and
move the cane and weaker leg forward together, then step through with
the stronger leg to maintain balance and support.
1. The nurse prepares to insert an indwelling urinary catheter. To
maintain a sterile field, the nurse should:
A. Turn away from the field while opening sterile supplies
B. Keep sterile objects at or above waist level
C. Reach across the sterile field to adjust the drape
D. Place sterile items 5 cm (2 in) from the field edge
Answer: B
Rationale: Sterile objects must remain at or above waist level and
within the field; turning away or reaching over the field risks
contamination, and the 2.5-cm (1-inch) edge is considered
contaminated.
1. A client is at risk for falls. Which nursing action is most effective to
help prevent a fall?
A. Keep two side rails raised at all times
RN® Examination, 9th Edition by Linda Anne Silvestri and Angela
Silvestri – Complete Questions and Answers (Pass Guaranteed)
|| Updated 2026 (strictly 100-150pages)
Fundamentals NCLEX Q&A With Rationales
1. The nurse is obtaining vital signs for an adult client. Which finding
requires immediate follow-up?
A. Respiratory rate 18 breaths/min
B. Blood pressure 118/76 mm Hg
C. Heart rate 124 beats/min
D. Oral temperature 37.2°C (99°F)
Answer: C
Rationale: A heart rate of 124 beats/min is tachycardia and may
indicate pain, anxiety, hypovolemia, or other acute problems that
require prompt assessment; the other values are within expected
ranges.
1. A nurse is preparing to administer morning medications. Which
action is the highest priority?
A. Explaining each medication to the client
B. Checking the client’s identification using two identifiers
C. Asking the client about food preferences
D. Documenting the medications to be given
,Answer: B
Rationale: Verifying the correct client using two identifiers is a core
patient-safety step and must occur before giving any medication to
prevent errors.
1. The nurse is reinforcing fire safety on a hospital unit. Which action
follows the RACE acronym correctly as the first step?
A. Close all doors to client rooms
B. Report the fire to the operator
C. Rescue clients in immediate danger
D. Extinguish the fire using the nearest extinguisher
Answer: C
Rationale: RACE stands for Rescue, Alarm, Contain, Extinguish; the first
priority is rescuing anyone in immediate danger before sounding the
alarm or attempting to extinguish the fire.
1. The nurse is caring for a client on contact precautions for
Clostridioides difficile infection. Which action is most appropriate?
A. Use an alcohol-based hand rub after removing gloves
B. Wear a surgical mask for all client contact
C. Wash hands with soap and water after removing gloves
D. Place the client in a negative-pressure room
Answer: C
Rationale: C. difficile forms spores that are not reliably removed by
alcohol; handwashing with soap and water is required after glove
removal to prevent transmission.
, 1. A client with limited English proficiency nods and says “yes” after
discharge teaching. The nurse suspects the client may not fully
understand. What is the best action?
A. Provide written instructions and ask the client to read them
later
B. Ask the family to explain the discharge instructions
C. Ask the client to repeat the information back in their own words
D. Continue with the next topic to avoid embarrassing the client
Answer: C
Rationale: The teach-back method (having the client restate
information) verifies understanding and allows the nurse to correct or
clarify any misunderstandings immediately.
1. The nurse is preparing to perform hand hygiene before a sterile
procedure. Which situation requires washing with soap and water
instead of alcohol-based hand rub?
A. Hands are visibly soiled
B. Before entering a client’s room
C. After removing clean gloves
D. After taking the client’s blood pressure
Answer: A
Rationale: Alcohol-based hand rub is appropriate when hands are not
visibly soiled; visible dirt or organic material requires washing with soap
and water.
, 1. The nurse is assisting a client to ambulate with a cane. Which
instruction is correct?
A. “Hold the cane on the weaker side.”
B. “Move the cane and weaker leg forward together.”
C. “Look at your feet while walking.”
D. “Place the cane 30–40 cm (12–16 in) in front of you.”
Answer: B
Rationale: The client should hold the cane on the stronger side and
move the cane and weaker leg forward together, then step through with
the stronger leg to maintain balance and support.
1. The nurse prepares to insert an indwelling urinary catheter. To
maintain a sterile field, the nurse should:
A. Turn away from the field while opening sterile supplies
B. Keep sterile objects at or above waist level
C. Reach across the sterile field to adjust the drape
D. Place sterile items 5 cm (2 in) from the field edge
Answer: B
Rationale: Sterile objects must remain at or above waist level and
within the field; turning away or reaching over the field risks
contamination, and the 2.5-cm (1-inch) edge is considered
contaminated.
1. A client is at risk for falls. Which nursing action is most effective to
help prevent a fall?
A. Keep two side rails raised at all times
