Saunders NCLEX‑RN 9th Edition
Test Bank — 100% Verified
Questions with Rationales, Pass
Guaranteed
,1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with stable angina reporting chest pain that started 30 minutes ago.
B. A client with type 2 diabetes whose blood glucose is 280 mg/dL.
C. A client who is 2 hours postoperative from a total hip replacement and is reporting
mild pain.
D. A client who had a colonoscopy 4 hours ago and is passing small amounts of bright
red blood.
Answer: A
Rationale: New‑onset chest pain in a client with heart disease is a priority because it
may indicate acute coronary syndrome or myocardial infarction, which is life‑threatening
and requires immediate assessment and intervention.
2. A nurse is preparing to delegate tasks to a licensed practical nurse (LPN). Which task is
appropriate to delegate?
A. Inserting a nasogastric tube for a postoperative client.
B. Administering the first dose of a new intravenous antibiotic.
C. Changing a sterile central line dressing for a client with sepsis.
D. Administering oral medications to a stable client with hypertension.
Answer: D
Rationale: Administering oral medications to a stable client is within the scope of LPN
practice when the route, medication, and client condition are stable. More invasive or
high‑risk procedures should be performed or supervised by the RN.
3. A nurse is developing a plan of care for a client who is disoriented and at risk for falls.
Which intervention is the priority?
A. Place the client in a room near the nurse’s station.
B. Request a prescription for a sedative medication.
C. Apply wrist restraints to prevent the client from getting out of bed.
D. Place a bed alarm and keep the bed in the lowest position.
Answer: D
Rationale: A bed alarm and keeping the bed low are non‑restraint, safety‑focused
interventions that reduce fall risk without violating the client’s autonomy or increasing risk
of injury. Restraints should only be used after all other measures fail and if legally and
ethically justified.
4. A nurse is suctioning a client with an endotracheal tube. Which action indicates correct
sterile technique?
A. Using a clean gloved hand to touch the outside of the suction catheter.
B. Touching the sterile catheter to the inside of the client’s mouth.
C. Wearing clean gloves and keeping the catheter sterile until insertion.
D. Using the same catheter for the mouth and trachea.
, Answer: C
Rationale: The suction catheter must remain sterile until it enters the airway; therefore,
the nurse should wear clean gloves and avoid contaminating the catheter. The catheter
should not be reused between the mouth and trachea to prevent infection.
5. A nurse is caring for a client who has just returned from the postanesthesia care unit
(PACU). Which assessment parameter is the priority?
A. Pain level.
B. Bowel sounds.
C. Airway and respiratory status.
D. Incision site appearance.
Answer: C
Rationale: After anesthesia, airway and breathing are the highest priorities because
respiratory depression or airway obstruction can occur quickly and be life‑threatening.
6. A nurse is teaching a client about informed consent for surgery. Which statement by the
client indicates understanding?
A. “I can sign the consent form anytime before the surgery.”
B. “I can withdraw my consent even after the procedure has started.”
C. “I only need to sign the consent if anesthesia is used.”
D. “I must sign the consent form before the nurse explains the procedure.”
Answer: B
Rationale: Informed consent is voluntary and can be withdrawn at any time, even after
the procedure begins. The client must also receive an explanation of the procedure and
risks before signing.
7. A nurse is caring for a client who is scheduled for a diagnostic colonoscopy. Which
intervention is most important before the procedure?
A. Provide nothing by mouth for 8 hours.
B. Administer a sedative 1 hour before the procedure.
C. Confirm the client has a reliable ride home.
D. Obtain a signed consent form.
Answer: C
Rationale: Colonoscopy uses moderate sedation, so the client cannot drive home
afterward. Ensuring a responsible adult driver is present is a safety requirement and a
priority before the procedure.
8. A nurse is reviewing assignments for the shift. Which client is most appropriate to assign
to a new graduate nurse?
A. A client with sepsis who is receiving multiple intravenous medications.
B. A client who is 24 hours postoperative from coronary artery bypass graft surgery.
C. A client with stable chronic obstructive pulmonary disease who is receiving oxygen via
nasal cannula at 2 L/min.
D. A client with a newly placed tracheostomy who requires frequent suctioning.
Answer: C
Rationale: A stable client with a chronic condition and simple oxygen therapy is
appropriate for a new graduate nurse, whereas clients with unstable conditions or
complex invasive devices should be cared for by more experienced nurses.
Test Bank — 100% Verified
Questions with Rationales, Pass
Guaranteed
,1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with stable angina reporting chest pain that started 30 minutes ago.
B. A client with type 2 diabetes whose blood glucose is 280 mg/dL.
C. A client who is 2 hours postoperative from a total hip replacement and is reporting
mild pain.
D. A client who had a colonoscopy 4 hours ago and is passing small amounts of bright
red blood.
Answer: A
Rationale: New‑onset chest pain in a client with heart disease is a priority because it
may indicate acute coronary syndrome or myocardial infarction, which is life‑threatening
and requires immediate assessment and intervention.
2. A nurse is preparing to delegate tasks to a licensed practical nurse (LPN). Which task is
appropriate to delegate?
A. Inserting a nasogastric tube for a postoperative client.
B. Administering the first dose of a new intravenous antibiotic.
C. Changing a sterile central line dressing for a client with sepsis.
D. Administering oral medications to a stable client with hypertension.
Answer: D
Rationale: Administering oral medications to a stable client is within the scope of LPN
practice when the route, medication, and client condition are stable. More invasive or
high‑risk procedures should be performed or supervised by the RN.
3. A nurse is developing a plan of care for a client who is disoriented and at risk for falls.
Which intervention is the priority?
A. Place the client in a room near the nurse’s station.
B. Request a prescription for a sedative medication.
C. Apply wrist restraints to prevent the client from getting out of bed.
D. Place a bed alarm and keep the bed in the lowest position.
Answer: D
Rationale: A bed alarm and keeping the bed low are non‑restraint, safety‑focused
interventions that reduce fall risk without violating the client’s autonomy or increasing risk
of injury. Restraints should only be used after all other measures fail and if legally and
ethically justified.
4. A nurse is suctioning a client with an endotracheal tube. Which action indicates correct
sterile technique?
A. Using a clean gloved hand to touch the outside of the suction catheter.
B. Touching the sterile catheter to the inside of the client’s mouth.
C. Wearing clean gloves and keeping the catheter sterile until insertion.
D. Using the same catheter for the mouth and trachea.
, Answer: C
Rationale: The suction catheter must remain sterile until it enters the airway; therefore,
the nurse should wear clean gloves and avoid contaminating the catheter. The catheter
should not be reused between the mouth and trachea to prevent infection.
5. A nurse is caring for a client who has just returned from the postanesthesia care unit
(PACU). Which assessment parameter is the priority?
A. Pain level.
B. Bowel sounds.
C. Airway and respiratory status.
D. Incision site appearance.
Answer: C
Rationale: After anesthesia, airway and breathing are the highest priorities because
respiratory depression or airway obstruction can occur quickly and be life‑threatening.
6. A nurse is teaching a client about informed consent for surgery. Which statement by the
client indicates understanding?
A. “I can sign the consent form anytime before the surgery.”
B. “I can withdraw my consent even after the procedure has started.”
C. “I only need to sign the consent if anesthesia is used.”
D. “I must sign the consent form before the nurse explains the procedure.”
Answer: B
Rationale: Informed consent is voluntary and can be withdrawn at any time, even after
the procedure begins. The client must also receive an explanation of the procedure and
risks before signing.
7. A nurse is caring for a client who is scheduled for a diagnostic colonoscopy. Which
intervention is most important before the procedure?
A. Provide nothing by mouth for 8 hours.
B. Administer a sedative 1 hour before the procedure.
C. Confirm the client has a reliable ride home.
D. Obtain a signed consent form.
Answer: C
Rationale: Colonoscopy uses moderate sedation, so the client cannot drive home
afterward. Ensuring a responsible adult driver is present is a safety requirement and a
priority before the procedure.
8. A nurse is reviewing assignments for the shift. Which client is most appropriate to assign
to a new graduate nurse?
A. A client with sepsis who is receiving multiple intravenous medications.
B. A client who is 24 hours postoperative from coronary artery bypass graft surgery.
C. A client with stable chronic obstructive pulmonary disease who is receiving oxygen via
nasal cannula at 2 L/min.
D. A client with a newly placed tracheostomy who requires frequent suctioning.
Answer: C
Rationale: A stable client with a chronic condition and simple oxygen therapy is
appropriate for a new graduate nurse, whereas clients with unstable conditions or
complex invasive devices should be cared for by more experienced nurses.
