Saunders NCLEX Test Questions with Answers Graded A
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
The nurse is assessing a client's postoperative pain using
3); Region or Radiation of the pain (option 1); Severity of
the PQRSTU method. Using this method, which questions
the pain; Timing of the pain (continuous or intermittent);
would the nurse ask the client?
and How the pain attects 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 Furosemide is a loop diuretic. The medication causes a
important laboratory test result for the nurse to check decrease in the client's electrolytes, especially potassi-
before administering this medication? um, sodium, and chloride. Administering furosemide to a
client with low electrolyte levels could precipitate ventric-
1-Blood urea nitrogen ular dysrhythmias. Options 1 and 4 reflect renal function.
2-Cholesterol level The cholesterol level is unrelated to the administration of
3-Potassium level this medication.
4-Creatinine level
A nurse caring for a client with a diagnosis of gastrointesti-
nal (GI) bleeding reviews the client's laboratory results 1- Report the abnormally low level.
and notes a hematocrit level of 30%. Which action should
the nurse take? The normal hematocrit level in a male ranges from 42% to
52%, and 35% to 47 % in a female, depending on age.
1- Report the abnormally low level. A hematocrit level of 30% is a low level and would be
2- Report the abnormally high level. reported to the health care provider because it indicates
3- Inform the client that the laboratory result is normal. blood loss; therefore options 2, 3, and 4 are incorrect.
4- Place the normal report in the client's medical record.
A nurse provides dietary instructions to a client who will 2- Spinach
be taking warfarin sodium (Coumadin). The nurse should
tell the client to avoid which food item? Warfarin sodium is an anticoagulant. Anticoagulant med-
ications act by antagonizing the action of vitamin K, which
1- Grapes is needed for clotting. When a client is taking an anticoag-
,Saunders NCLEX Test Questions with Answers Graded A
2- Spinach ulant, foods high in vitamin K often are omitted from the
3- Watermelon diet. Vitamin K-rich foods include green leafy vegetables,
4- Cottage cheese fish, liver, cottee, and tea.
2-Air embolism
A client who has been receiving total parenteral nutrition
(TPN) by way of a central venous access device complains The signs and symptoms of air embolism include chest
of chest pain and dyspnea. The nurse quickly assesses pain, dyspnea, hypoxia, anxiety, tachycardia, and hypoten-
the client's vital signs and notes that the pulse rate has sion. The nurse also may hear a loud churning sound over
increased and the blood pressure has dropped. The nurse the pericardium on auscultation of the client's chest. The
determines that the client is most likely experiencing signs and symptoms of sepsis include fever, chills, and
which problem? general malaise. Fluid overload causes increased intravas-
cular volume, which increases the blood pressure and the
1- Sepsis pulse rate as the heart tries to pump the extra fluid vol-
2- Air embolism ume. Fluid overload also causes neck vein distention and
3- Fluid overload shifting of fluid into the alveoli, resulting in lung crackles.
4- Fluid imbalance The signs and symptoms of a fluid imbalance depend on
the type of imbalance the client is experiencing.
1- Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
A client who is receiving intravenous (IV) fluid therapy
complains of burning and a feeling of tightness at the IV An infiltrated IV line is one that has dislodged from the vein
insertion site. On assessment, the nurse detects coolness and is lying in subcutaneous tissue. Pallor, coolness, and
and swelling at the site and notes that the IV rate has swelling at the IV site result when IV fluid is deposited in
slowed. The nurse determines that which complication the subcutaneous tissue. When the pressure in the tissues
has occurred? 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.
, Saunders NCLEX Test Questions with Answers Graded A
A nurse provides instructions to a preoperative client 4-After maximal inspiration, hold the breath for 10 sec-
about the use of an incentive spirometer. The nurse deter- onds and then exhale.
mines that the client needs further instruction if the client
indicates that he or she will take which action? For optimal lung expansion with the incentive spirometer,
the client should assume a semi-Fowler's or high Fowler's
1- Sit upright when using the device. position. The mouthpiece should be covered completely
2- Inhale slowly, maintaining a constant flow. and tightly while the client inhales slowly, with a con-
3- Place the lips completely over the mouthpiece. stant flow through the unit. When maximal inspiration
4- After maximal inspiration, hold the breath for 10 sec- is reached, the client should hold the breath for 2 or 3
onds and then exhale. seconds and then exhale slowly
2- The chest tube is functioning as expected.
The nurse is monitoring a client who has a closed chest The presence of fluctuation of the fluid level in the wa-
tube drainage system. The nurse notes fluctuation of the ter-seal chamber indicates a patent drainage system. With
fluid level in the water-seal chamber during inspiration normal breathing, the water level rises with inspiration
and expiration. On the basis of this finding, the nurse and falls with expiration. Fluctuation stops if the tube is
should make which interpretation? obstructed, if the suction is not working properly, or if
the lung has re-expanded. Options 1, 3, and 4 are incor-
1- There is a leak in the system. rect interpretations of the finding. An air leak may cause
2- The chest tube is functioning as expected. excessive bubbling in the water seal chamber. Excessive
3- The amount of suction needs to be decreased. and vigorous bubbling in the suction control chamber may
4- The occlusive dressing at the insertion site needs rein- indicate that the amount of suction needs to be decreased.
forcement. The status of the dressing is not specifically related to the
presence of fluctuation of the fluid level in the water-seal
chamber
A nurse is providing morning care to a client who has a 1- Call the health care provider.
closed chest tube drainage system to treat a pneumoth-
orax. When the nurse turns the client to the side, the If the chest drainage system is dislodged from the inser-
chest tube is accidentally dislodged from the chest. The tion site, the nurse immediately applies sterile gauze over
nurse immediately applies sterile gauze over the chest the site and calls the health care provider. The nurse would
tube insertion site. Which is the nurse's next action? maintain the client in an upright position. A new chest tube
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
The nurse is assessing a client's postoperative pain using
3); Region or Radiation of the pain (option 1); Severity of
the PQRSTU method. Using this method, which questions
the pain; Timing of the pain (continuous or intermittent);
would the nurse ask the client?
and How the pain attects 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 Furosemide is a loop diuretic. The medication causes a
important laboratory test result for the nurse to check decrease in the client's electrolytes, especially potassi-
before administering this medication? um, sodium, and chloride. Administering furosemide to a
client with low electrolyte levels could precipitate ventric-
1-Blood urea nitrogen ular dysrhythmias. Options 1 and 4 reflect renal function.
2-Cholesterol level The cholesterol level is unrelated to the administration of
3-Potassium level this medication.
4-Creatinine level
A nurse caring for a client with a diagnosis of gastrointesti-
nal (GI) bleeding reviews the client's laboratory results 1- Report the abnormally low level.
and notes a hematocrit level of 30%. Which action should
the nurse take? The normal hematocrit level in a male ranges from 42% to
52%, and 35% to 47 % in a female, depending on age.
1- Report the abnormally low level. A hematocrit level of 30% is a low level and would be
2- Report the abnormally high level. reported to the health care provider because it indicates
3- Inform the client that the laboratory result is normal. blood loss; therefore options 2, 3, and 4 are incorrect.
4- Place the normal report in the client's medical record.
A nurse provides dietary instructions to a client who will 2- Spinach
be taking warfarin sodium (Coumadin). The nurse should
tell the client to avoid which food item? Warfarin sodium is an anticoagulant. Anticoagulant med-
ications act by antagonizing the action of vitamin K, which
1- Grapes is needed for clotting. When a client is taking an anticoag-
,Saunders NCLEX Test Questions with Answers Graded A
2- Spinach ulant, foods high in vitamin K often are omitted from the
3- Watermelon diet. Vitamin K-rich foods include green leafy vegetables,
4- Cottage cheese fish, liver, cottee, and tea.
2-Air embolism
A client who has been receiving total parenteral nutrition
(TPN) by way of a central venous access device complains The signs and symptoms of air embolism include chest
of chest pain and dyspnea. The nurse quickly assesses pain, dyspnea, hypoxia, anxiety, tachycardia, and hypoten-
the client's vital signs and notes that the pulse rate has sion. The nurse also may hear a loud churning sound over
increased and the blood pressure has dropped. The nurse the pericardium on auscultation of the client's chest. The
determines that the client is most likely experiencing signs and symptoms of sepsis include fever, chills, and
which problem? general malaise. Fluid overload causes increased intravas-
cular volume, which increases the blood pressure and the
1- Sepsis pulse rate as the heart tries to pump the extra fluid vol-
2- Air embolism ume. Fluid overload also causes neck vein distention and
3- Fluid overload shifting of fluid into the alveoli, resulting in lung crackles.
4- Fluid imbalance The signs and symptoms of a fluid imbalance depend on
the type of imbalance the client is experiencing.
1- Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
A client who is receiving intravenous (IV) fluid therapy
complains of burning and a feeling of tightness at the IV An infiltrated IV line is one that has dislodged from the vein
insertion site. On assessment, the nurse detects coolness and is lying in subcutaneous tissue. Pallor, coolness, and
and swelling at the site and notes that the IV rate has swelling at the IV site result when IV fluid is deposited in
slowed. The nurse determines that which complication the subcutaneous tissue. When the pressure in the tissues
has occurred? 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.
, Saunders NCLEX Test Questions with Answers Graded A
A nurse provides instructions to a preoperative client 4-After maximal inspiration, hold the breath for 10 sec-
about the use of an incentive spirometer. The nurse deter- onds and then exhale.
mines that the client needs further instruction if the client
indicates that he or she will take which action? For optimal lung expansion with the incentive spirometer,
the client should assume a semi-Fowler's or high Fowler's
1- Sit upright when using the device. position. The mouthpiece should be covered completely
2- Inhale slowly, maintaining a constant flow. and tightly while the client inhales slowly, with a con-
3- Place the lips completely over the mouthpiece. stant flow through the unit. When maximal inspiration
4- After maximal inspiration, hold the breath for 10 sec- is reached, the client should hold the breath for 2 or 3
onds and then exhale. seconds and then exhale slowly
2- The chest tube is functioning as expected.
The nurse is monitoring a client who has a closed chest The presence of fluctuation of the fluid level in the wa-
tube drainage system. The nurse notes fluctuation of the ter-seal chamber indicates a patent drainage system. With
fluid level in the water-seal chamber during inspiration normal breathing, the water level rises with inspiration
and expiration. On the basis of this finding, the nurse and falls with expiration. Fluctuation stops if the tube is
should make which interpretation? obstructed, if the suction is not working properly, or if
the lung has re-expanded. Options 1, 3, and 4 are incor-
1- There is a leak in the system. rect interpretations of the finding. An air leak may cause
2- The chest tube is functioning as expected. excessive bubbling in the water seal chamber. Excessive
3- The amount of suction needs to be decreased. and vigorous bubbling in the suction control chamber may
4- The occlusive dressing at the insertion site needs rein- indicate that the amount of suction needs to be decreased.
forcement. The status of the dressing is not specifically related to the
presence of fluctuation of the fluid level in the water-seal
chamber
A nurse is providing morning care to a client who has a 1- Call the health care provider.
closed chest tube drainage system to treat a pneumoth-
orax. When the nurse turns the client to the side, the If the chest drainage system is dislodged from the inser-
chest tube is accidentally dislodged from the chest. The tion site, the nurse immediately applies sterile gauze over
nurse immediately applies sterile gauze over the chest the site and calls the health care provider. The nurse would
tube insertion site. Which is the nurse's next action? maintain the client in an upright position. A new chest tube
